Patient Forms
Please bring your completed forms with you to our office at the time of your visit. To view the documents listed on this page, you will need Adobe Reader.
Online questionnaires can be completed through your MyChart Patient Portal when it is associated with a visit.
Release Forms
- Authorization to Release Health Information
For Transfers Out, Transfers In, Copy for Self and Coordination of Care with family or schools - Authorization for to Release Medical Information to Family Members
For patients 18 years old or older to share information with family members - Authorization to Release Sensitive Health Information
For sensitive information like HIV/AIDS, Genetic Information, Alcohol and/or Drug Abuse or Sexually Transmitted Diseases - Authorization to Release Behavioral Health Information – Two Way Communication – English
Authorization to Release Behavioral Health Information – Two Way Communication – Spanish
For therapists and facilities to have 2 way conversation with our integrated behavioral health team and providers - Authorization to Release Psychotherapy Notes
For requesting integrated behavioral health notes from NAP
For New Patients
Medical Consent Authorization / Limited Power of Attorney
New Medical Consent Form Now Available
To help families plan ahead for travel, vacations, or when a child will be attending an appointment with another trusted adult, Northampton Area Pediatrics, LLP now offers a Medical Consent Authorization / Limited Power of Attorney form on our website.
This form allows a parent or legal guardian to authorize another adult to bring a child to appointments and consent to certain medical care when the parent is unavailable.
If your child may be seen with a grandparent, relative, babysitter, or other caregiver, we encourage you to complete this form in advance.
The form is available for download on our website. Please contact our office if you have any questions. Medical Consent Form
Caregiver Authorization Affidavit (Massachusetts)
New Form Available
Caregiver Authorization Affidavit
To help families manage situations where a child may be temporarily living with or cared for by another trusted adult, Northampton Area Pediatrics, LLP provides access to the Massachusetts Caregiver Authorization Affidavit form on our website.
This form allows a parent or legal guardian to authorize a caregiver—such as a grandparent, relative, or family friend—to make certain decisions related to a child’s education and health care when the parent is unavailable.
If your child may be temporarily living with or primarily cared for by another adult for an extended period of time, we encourage you to complete this form in advance.
The form is available for download on our website. Please contact our office if you have any questions.
Please note: This affidavit allows a caregiver to act on behalf of a parent for certain purposes but does not transfer legal custody or guardianship.