HIPAA

HIPAA

Contact Information/Privacy Consent
17 Research Dr., Amherst, MA 01002

6 Hatfield Street Northampton, MA 01060

413-549-8400 ~ atkinsonfamilypractice.com
Patient Name:
Date of Birth
Date

MonthDayYear
Date
Pronouns:
Address

Address

Street Address Line 2

CityState

Zip
Phone Number (Home)

Area CodePhone Number
How do you want to receive a reminder of an upcoming appointment?
May we leave a message and/or medical info?

YESNO
Phone Number (Work)

Area CodePhone Number
May we leave a message and/or medical info?

YESNO
Phone Number (Cell)

Area CodePhone Number
May we leave a message and/or medical info?

YESNO
Which is your primary phone number?

HomeWorkCell
How do you want to receive a reminder of an upcoming appointment?

Text MessageEmail
Do you have an email address?

YESNO
Please provide your email address by printing clearly on the line below:
example@example.com
Due to HIPAA regulations, we may only discuss health information with people that you have listed below (that includes parents and/or spouses).

Please list all people that we may speak to about you and your medical status

Please note that this consent will be valid for one year (from date signed)*. If your contact information changes before the end date, please complete a new form. This may be revoked at any time, in writing. The information is for your protection and we appreciate your cooperation in protecting you and your rights.
Patient/Legal Representative Signature

Clear
*Date:

MonthDayYear
Date
Valid for one year from this date
Should be Empty: