Medical Release AFP to OCC

Authorization for Release of Medical Information from AFP to OCC

Only for patients of Atkinson Family Pracrice
Last
First
Date of Birth

Month Day Year
Date
Parent/Guardian Name
Previous/Maiden Name
Street
Apt. #
City
State
Zip Code
Primary Phone
Email Address
example@example.com
Consent for Communication
I consent to communications from Origins Collaborative Care PLLC via the patient portal using the above listed email address (please initial).
I consent to communication regarding my care using above listed phone number (please initial).
Obtain & Disclose Medical Records
I hereby authorize Atkinson Family Practice to release my health information to Origins Collaborative Care PLLC (please initial).
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.
HIV/AIDS
sexually transmitted disease
mental health/psychiatry
drug/alcohol use & treatment
This authorization will expire one year from date of signature unless otherwise stated here:
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:
Signature of patient or authorized representative

Clear
Print name of patient or authorized representative
Date

Month Day Year
Date
Should be Empty: