• Nike Carli, LCSW-R

    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


  • 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:

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