Bend Psychological Services
965 NE Wiest Way,  No. 2,  Bend Oregon 97701
Office: (541) 388-5660   Fax: 541 323-2000

This form when completed and signed by you (signature below), authorizes the designates person to release to others or to obtain protected information  from your clinical record.

Client Name(s): ________________________________________________________

Client Date(2)  of Birth: _____________________________

I authorize my psychologist, Michael Conner, Psy.D or his staff  to release the following information verbally and in writing to: _____________________________________________________________________

(Please Initial)

_____  Permission to Discuss Case

_____  Psychological Reports

_____  Psychotherapy/Counseling Notes

_____  Other: __________________________________________________________

I authorize  _____________________________________________________________

to release the following  to Michael G. Conner

(Please Initial)

_____  Permission to Discuss Case

_____  Psychological Reports

_____  Psychotherapy/Counseling Notes

_____  Other: __________________________________________________________

This authorization shall remain in effect until One Year from date signed below.

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.

Name of Patient(s), Client(s) or Authorized person(s):

_____________________________________________________________________________________

Signature of Patient, Client or Authorized person:

_____________________________________________________________________________________

Date: _____________________________

Representative's Authority: _______________________________________________

Description of Authority: __________________________________________________