Practice Contact Information:
Atkinson Family Practice, 17 Research Dr., Amherst, MA 01002. Phone: 413-549-8400; Fax: 413-549-8409
Origins Collaborative Care, PLLC, Amherst, MA. Phone: 413-200-9897; Fax: 413-417-2547.
The purpose of this release: continuity of care (not leaving the practice)
Medical Information to be disclosed: Progress notes, consultations, labs, imaging, and other documents related to Functional Medicine consultation and treatment.
Release of sensitive/protected information
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.
Please indicate the areas you authorize by initialing each box below. We recommend you authorize all areas to simplify the record transfer process.
I understand that I may revoke this authorization at any time by making a written request to Origins Collaborative Care. I understand that actions taken in reliance on this authorization prior to revocations may not be reversible. I understand that Origins Collaborative Care may not condition treatment, payment, enrollment or eligibility for benefits on my signing this authorization. State law prohibits redisclosure without written authorization.
I acknowledge that I have signed this authorization voluntarily: