This form when completed and signed by you (signature below),
authorizes the person you designate to release or obtain protected information
to or from
your clinical record to .
|
Release of information from Michael Conner, Psy.D to Another
Person or Party (Please Initial)
_____ I authorize my psychologist, Michael Conner, Psy.D to release the
following information verbally and in writing to:
__________________________________________________________ |
| Release of information to Michael G. Conner,
Psy.D from Another Person or Third Party
(Please Initial)
_____ I authorize
___________________________________________ (name of professional
or organization) or their administrative and clinical staff to
release the following information verbally and in writing to Michael
Conner, Psy.D |
| Information to be Released: (Please Initial)
_____ Screening Information:
______________________________________________
_____ Behavioral and Psychological Reports:
__________________________________
_____ Treatment Plan:
___________________________________________________
_____ Discharge Summary:
________________________________________________
_____ Medical History:
___________________________________________________
|
|
I am requesting my psychologist to
release this information for the following reasons:
(Please Initial)
______ To provide consulting
services |
|
This authorization shall remain in
effect until
Expiration date: _____________________,
|
This authorization may be revoked at any time. The only exception is
when action has been taken in reliance on the authorization. I understand that Dr. Conner generally may not condition
psychological services upon signing an authorization unless the
psychological services are provided for the purpose of creating
health information for a third party.
Name of Parent or Authorized person (print) :
________________________________________
Signature of Parent or Authorized person: ___________________________________________
Date: __________________
Name of Parent or Authorized person (print) :
________________________________________
Signature of Parent or Authorized person: ___________________________________________
Date: __________________
(If a Personal Representative/Authorized person for the
patient/client signs the authorization, a description of such
representative's authority to act for the patient must be provided.)
Representative's Authority:
________________________________________________________