Date of Birth
Consistent with California and Federal Law I authorize the disclosure and use of my Protected Health Information (PHI).
Bonnie Connor, Ph.D., Licensed Psychologist PSY 22446
, is authorized to communicate (verbally or in writing) anything that has been brought up during neuropsychological evaluation or psychotherapy treatment with any person(s) or staff of clinic, office, agency, or institution/s named below
any relevant information
For the following reason(s):
My Rights as a Patient:
I have a right to receive a copy of this authorization. I may revoke this consent at any time. The revocation of this authorization will be effective upon written receipt except when action has been taken in reliance on this authorization. This authorization will be placed in my flle. I understand any cancellation or modification of this authorization, to be effective, must be in writing and received by Bonnie Connor, PhD at 2950 Buskirk Avenue, Suite 300, Walnut Creek, CA 94597.
I have the right to refuse to sign this form and my health treatment or fees will not be conditioned upon whether or not I sign this authorization. Information disclosed pursuant to this authorization to a party not required to keep it confidential may be subject to re-disclosure and may no longer be protected by the HIPAA Privacy Rule, although applicable California law may protect such information.
This consent is in effect only for five (5) years from the date of the last session, unless revoked in writing earlier or renewed. This consent is also subject to all conditions outlined in the Office Policies form.
Patient's Signature (typed)
Patient's Representative Signature (Parent, Guardian, Conservator) (typed)
If signed by someone other than the patient, state your legal relationship to the patient and your authority to act on his or her behalf.