Derryfield Medical Group: Patient Information

To schedule, cancel, or reschedule an appointment, please call our office at 603-624-8652 or log into your MyChart account. If you do not have a MyChart account, please click here to sign up.

Insurance Card, including your policy number and/or Medicare/Medicaid card. 

Co-payment is expected when you check in. For your convenience we accept checks, cash, Visa, Mastercard, Discover, and American Express. 

Prescription Medication(s) in their original bottles or a list of all medications, including over-the-counter medications, vitamins, and supplements, and the amounts you take.

To refill a prescription, please call our office at 603-624-8652 or log into your MyChart account. If you do not have a MyChart account, please click here to sign up.

Please allow 48 hours to refill medications.

To request a referral, please call our office at 603-624-8652 or log into your MyChart account. If you do not have a MyChart account, please click here to sign up.

If you would like a copy of your medical record, please download and complete the form below. Completed forms can be mailed, faxed, or brought back to our office.

Medical Records Release Form 

Download the SolutionHealth MyChart Parent/Guardian Access Form by logging into your MyChart account here.

NICHQ Vanderbilt Assessment Follow-up PARENT Informant

NICHQ Vanderbilt Assessment Follow-up TEACHER Informant

NICHQ Vanderbilt Assessment Scale – PARENT Informant

MCHAT Autism Screening

Medicare covers an Annual Wellness Visit with your primary care provider. There are no co-pays or deductibles for this visit.

Your first Annual Wellness Visit will include, among other things, a medical history, health risk assessment, and an evaluation of physical condition and screening for cognitive impairment. In addition, your doctor will work with you to set a prevention plan, including appropriate health screenings. 

Medicare Annual Wellness Visit 

Medicare is a federal health insurance program for people aged 65 or older and younger people receiving Social Security disability benefits. 

Understanding Medicare Services

Informed Consent Prescribing Agreement - Benzodiazepines and Barbiturates

Informed Consent Prescribing Agreement - Stimulants