• 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

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  • I hereby authorize the below named Physician/Facility to release my health information to: Atkinson Family Practice, 17 Research Dr., Amherst, MA 01002 ~ Phone: 413-549-8400; FAX: 413-549-8409

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  • This Authorization Covers:

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  • 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.

  • This authorization EXPIRES ON: (if unspecified, one year from date of signature)

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  • 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:

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