Release of Information
I ________________________________, SS# _________________________, request all files related to my documented disability be released to Mary Helen Walker. I understand the information requested is confidential in nature. This release is subject to revocation in writing at any time, but revocation can have no effect on disclosures previously made. This authorization expires without express revocation one year from the date, which appears below.
Signature of Client: _______________________________________
Mary Helen Walker, MA, NCC, NCLPC
Director, Disability Support Services
P.O. Box 1510
One University Drive
Pembroke, NC 28372