Applications, Guides and Forms

How to Apply

If you would like to apply to SeaCare, please contact a Care Coordinator at our main office at (603) 772-8119.  A Care Coordinator will ask you a few questions to determine your eligibility.  You can download our program application below, however, our Care Coordinators welcome you to make a pre-enrollment or a pre-certification visit with us to complete your application.  We know that the paperwork seems overwhelming and we can help you complete it, provide release request forms and direct you to the places you need to go to get copies of your personal documentation.

The paperwork necessary to enroll in SeaCare is part of a statewide method of determining income. Using this system allows us to make a smoother transition for you from one health care program to another.   What are these systems?

• Exeter Hospital Financial Assistance
• Core Physicians
• NH Health Access Network (NHHAN) used by Portsmouth Regional Hospital and all hospitals across the state
• Referrals for specialty care

Please see below for our applications, guides and forms – simply click on each document to download it to your computer.  If you have any questions, need assistance or would like any of these documents mailed to you, please contact a Care Coordinator at our main office at (603) 772-8119.  Let other people know that we can help them too!  Thank You!

Program Application – enrollment application for the Medical Access Program.

Required Documentation List - documents we will need to enroll you in the program.

Gross Income Estimate Worksheet – use this worksheet to determine your gross income.

Participant Guide - a helpful guide for participants enrolled in the program.

Recertification Form – download this form if the dates on your card are about to expire or have expired.

Notice of Health Information – HIPAA