Autism Report | Bureau of Developmental Services | New Hampshire Department of Health and Human Services

NHDHHS Autism Spectrum Disorder Registry Reporting Form

All fields are required.

PATIENT INFORMATION

Patient's first initial of last name:

Last 4 digits of Patient's SSN#:

Birth Date (mm/dd/yyyy):

Gender:

Residence at Birth:

(City/Town)
(State)

NH Residence at time of diagnosis:

(City/Town)
(State)	New Hampshire

Ethnicity/Race:

White (Non Hispanic)	American Indian/Alaskan Native
Black (Non Hispanic)	Native Hawaiian or other Pacific Islander
Hispanic	Asian
Not Reported	Other

Other (please Specify):

DIAGNOSIS INFORMATION

Please select either DSM-V or ICD-10 but not both

REPORTER INFORMATION

Name (First, MI, Last):

Degree (select one):

Other (please Specify):

If you have any questions please feel free to contact Erika Downie at:

Phone: 1-800-852-3345, Ext. 4488 (NH only) or (603) 271-4533 Fax: (603) 271-4902

The following information was submitted; please print a copy for your records.

PATIENT INFORMATION

* Patient's first initial of last name:

* Last 4 digits of Patient's SSN#:

* Birth Date (mm/dd/yyyy):

* Gender:

* Residence at Birth:

(City/Town)
(State)

* NH Residence at time of diagnosis:

(City/Town)
(State)	New Hampshire

* Ethnicity/Race:

DIAGNOSIS INFORMATION

REPORTER INFORMATION

If you have any questions please feel free to contact Erika Downie at:

Phone: 1-800-852-3345, Ext. 4488 (NH only) or (603) 271-4533 Fax: (603) 271-4902

New Hampshire Department of Health and Human Services
129 Pleasant Street | Concord, NH | 03301-3852