• skellylicsw@gmail.com
  • 413- 842-8500
  • skellylicsw@gmail.com
  • 413- 842-8500

Authorisation for release

Authorisation for release

    Sandra L. Kelly, LICSW

    21 Paulding Dr. South Chatham, MA 02659
    413-230-0508
    skellylicsw@gmail.com

    AUTHORIZATION FOR RELEASE/REQUEST OF CONFIDENTIAL INFORMATION
    Permission is hereby given to Sandra L Kelly LICSW to
    information for professional use, from the records of:

    This authorization includes the release of psychological and/or psychiatric information which may be part of the medical record.

    Person/organization to/from which information is to be
    (12 months unless specified)

    The type of information is limited to (check at least one):

    I understand that I may revoke this consent at any time in writing EXCEPT to the extent that action may have already been taken in reliance on my consent. I also hereby release Sandra Kelly from any liability in connection with the release of the above information.