• Authorization for Release of Medical Information from AFP to OCC

    Only for patients of Atkinson Family Pracrice
  •  /  /
    Pick a Date
  • Consent for Communication

  • Obtain & Disclose Medical Records

  • 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:

  • Clear
  •  /  /
    Pick a Date
  •  
  • Should be Empty:
Jotform Logo
Now create your own Jotform - It's free! Create your own Jotform