516-914-8344
28 East Old Country Road Hicksville, NY 11801
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AUTHORIZATION OF RELEASE SCHOOL RECORDS

I hereby authorize the release of records, documents, or other information concerning DOB

The named individual’s attorney and/or his/her representative.

This release covers all school records, including but not limited to, records pertaining to discipline, expulsions, suspensions, attendance, grades, transcripts, testing results and special education.

I understand that (enter name below) and his/her staff will regard as confidential and privileged any information thus released to them, and will use said information for the sole purpose of assisting me with the legal matters upon which I Have sought their advise and assistance.

A copy of this Authorization shall be as valid as the original. This authorization is effective immediately and expires one year from the date below.

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At AMK Psychiatry PLLC, your path to mental wellness is accompanied by a committed and reliable partner, Dr. Ali Khan.

Offering dependable and compassionate care tailored to meet your unique needs, you are invited to explore the services, knowing that your mental health is the top-most priority.

School Release Form

AUTHORIZATION OF RELEASE SCHOOL RECORDS

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