• ATKINSON FAMILY PRACTICE

    17 Research Dr., Amherst, MA 01002; 6 Hatfield St., Northampton, MA 01060

    Ph: 413-549-8400; Fax: 413-549-8409

  • Authorization to Disclose Medical Information

    ALL SECTIONS BELOW MUST BE COMPLETED FOR PROCESSING
  • 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 (month/year). *. (If unspecified, 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:

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