Nike Carli, LCSW-R ~Authorization For Release of Healthcare Information

Nike Carli, LCSW-R

5500 Main Street, Suite 259, Williamsville, New York 14221 Phone: 716-633-6900
Authorization For Release of Healthcare Information Primary Care Physician
Name

First NameLast Name
Birth Date

MonthDayYear
Email

Confirmation Emailexample@example.com
Primary Care Physician's Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Purpose: Coordination of treatment.

I hereby authorize the release of the above information from my record. I understand that the information to be released from my record is confidential and protected from disclosure. I also understand that I have the right to cancel my permission to release information at any time before it is released. I also understand that my consent to release information will expire:
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient Signature
Should be Empty:

Nike Carli, LCSW-R