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 Name Last Name
Relationship to Patient *
Maiden or Former Name *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Date of Birth *
Date of Birth:

Month Day Year
Date
*

OBTAIN MEDICAL RECORDS -
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
Previous Physician/Practice: *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Fax Number: *

Area Code Phone Number
DISCLOSE MEDICAL RECORDS - I hereby authorize Atkinson Family Praxtice to release my health information to:
New Physician/Practice
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Fax Number:

Area Code Phone Number
Purpose of This Release: *

Transfer** Continuity of Care (not leaving practice) Legal Insurance Consult Appointment Personal
Medical Information to be Released: *

All Records Consultations Diagnosis Tests (labs. x-rays, EKG, colonoscopy, etc). Hospital Notes Progress Notes Immunizations
Authorization Covers: *

Past Three Years Entire Period of Care, Which Began
Month and Year *
Date

Month Day Year
Date
*

Specific Dates
Start Date

Month Day Year
Date
Start Date to End Date *
End Date

Month Day Year
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 EXPIRES ON:
Month and Year *
Date

Month Day Year
Date
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 *
Signature of Patient or Authorized Representative

Clear
Date *

Month Day Year
Date
If you are transferring out of AFP, would you kindly tell us why? Your feedback is so important to us, so we can ensure our patients receive only the finest care. Please be specific. Thank you!
Should be Empty:

Now create your own JotForm - It's free! Create your own JotForm