Name(s): _______________________________________________________________________________________ Date of Birth: _____________________________ Release of Information I authorize Michael
Conner, Psy.D or his staff to release the following information
verbally and in writing to: ________________________________________________________________________________________________ (Please Initial) _____ Screening Information _____ Behavioral and Psychological Reports _____ Treatment Plan _____ Psychotherapy/Counseling Notes _____ Other: __________________________________________________________ I authorize _____________________________________________________________ to release the following information verbally and in writing to Michael Conner, PsyD (Please Initial) _____ Screening Information _____ Behavioral and Psychological Reports _____ Treatment Plan _____ Psychotherapy/Counseling Notes _____ Other: __________________________________________________________ I am requesting this release this information for the following reasons: ______ To provide services and care, or ______ (other purpose) ____________________ 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. Unless revoked this release shall remain in effect for the period reasonably needed to complete the request. I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient of your information and no longer protected by the HIPAA privacy rule. Print Name of Patient(s), Client(s) or Authorized person(s) (parent, guardian): ______________________________________________________________________ ______________________________________________________________________ Date
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