Release of info
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  AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION   
Full Name
Relationship to child
Please complete one form for each individual (doctor, school staff, etc.) with whom Dr. Kelly can communicate.

I hereby authorize the communication between parties noted below as well as the release of my child’s health information to NECCA.
Child's Full Name
Date of Birth
MM
/
DD
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YYYY
Pediatrician/Physician’s name:
Pediatrician/Physician’s address:
Pediatrician/Physician’s City, State, Zip:
School Name:
School address:
School City, State, Zip:
Other’s name:
Other’s address:
Other's City, State, Zip:
I understand and acknowledge that this may include alcohol/drug abuse, mental health, or medically sensitive information.

Purpose of disclosure: Neuropsychological or Psychoeducational Evaluation

I give my permission for the information listed above to be released to the above named requestor.  I understand that I may revoke this authorization at any time, except to the extent that action has already been taken to comply with it.  This authorization will expire 90 days after the date signed.  The requestor should not redisclose my child’s medical record to another party without further written consent. I will not hold NECCA or Dr. Kelly liable for any injury, whether mental or physical, resulting from any misunderstanding of information in the released report as a result of my not asking Dr. Kelly for clarification of the information therein.
Signature of name insured:
By typing my name in the field below, I agree it is equivalent to my signature on this document and I consent to conduct the transaction to which this document is applicable by electronic means.
Witness
Date:
MM
/
DD
/
YYYY
Typing your name on the signature line is representative of a legally binding e-signature
 *
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