Authorization for Release of Medical Information

17 Research Dr., Amherst, MA 010026 Hatfield Street, Northampton, MA 01060 Phone: 413-549-8400; FAX: 413-549-8409
Authorization for Release of Medical Information

All sections below must be completed for processing
Patient Name:*

First NameLast Name
Relationship to Patient*
Maiden or Former Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Date of Birth*
Date of Birth:

MonthDayYear
Date
OBTAIN MEDICAL RECORDS -
I hereby authorize the below named Physician/Facility to release my health information to: Atkinson Family Practice- 17 Research Drive, Amherst MA., 01002 - 413-549-8400
Previous Physician/Practice:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Fax Number:*

Area CodePhone Number
DISCLOSE MEDICAL RECORDS - I hereby authorize Atkinson Family Praxtice to release my health information to:
Phone Number

Area CodePhone Number
Fax Number:

Area CodePhone Number
Purpose of This Release:*

Transfer **Continuity of Care (not leaving practice)LegalInsuranceConsult AppointmentPersonalOther
Medical Information to be Released:*

All RecordsConsultationsDiagnosis Tests (labs. x-rays, EKG, colonoscopy, etc).Hospital NotesProgress NotesImmunizationsOther
Authorization Covers:

Past Three YearsEntire Period of Care (input approximate start date below)Specific Dates (input below in "start to end date")
This Authorization Covers:

Please specify the time frame from the options below.
Past Three Years
Entire Period of Care
Beginning on (first month and year):
Specific Dates
Start to End Date
Specific Dates
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Release of sensitive, protected information related to testing, diagnosis and/or treatment for HIV/AIDs, sexually-transmitted diseases, drug/alcohol use/treatment, and/or mental health/psychiatry is authorized only through express consent.

INDICATE THE AREAS YOU AUTHORIZE BY INITIALING EACH ONE BELOW. AUTHORIZATION IS NOT VALID UNLESS INITIALED.
HIV/AIDs
Sexually Transmitted Diseases
Mental Health/Psychiatry
Drug/Alcohol Dependency
This authorization will expire one year from date of signature.
I understand that I may revoke this authorization at any time by making a written request to Atkinson Family Practice. I understand that actions taken in reliance on this authorization prior to revocations may not be reversible. I understand that Atkinson Family practice may not condition treatment, payment, enrollment or eligibility for benefits on my signing this authorization. State law prohibits re-disclosure without written authorization.

I acknowledge that I have signed this Authorization voluntarily:
Printed Name of Patient/Authorized Representative*
Signature of Patient or Authorized Representative

Clear
Today's Date*

MonthDayYear
Date
Should be Empty:

Authorization for Release of Medical Information

This Authorization Covers: