I, First Name* Last Name* , authorize Dr. Oakley to release and receive any and all information as it pertains to my psychological, emotional, and medical status for which I am being evaluated to: Information to be disclosed pertains to assessment of my emotional and psychological status and may include any and all information including psychological test results and interpretation, diagnosis, the history of injury which I present, Dr. Oakley's opinions related to my psychological status or referral questions such as need for treatment, whether my emotional status is work-related or due to non-industrial factors, a discussion of whether or not non-industrial factors play a role in any disability, need for treatment, or emotional status, and the reasons why Dr. Oakley has arrived at these opinions. Dr. Oakley may also discuss whether or not any disability can be apportioned to pre-existing conditions or non-industrial causes. I understand that although this information will be released only to those parties with the legal right to review the basis for my claim of injury, Dr. Oakley loses control over who received this information once it is released, and this information could be obtained by legal counsel, obtained by me, a WCAB judge, as well as my employers as part of their legal right to review that basis of my claim. My employers have the legal right to conduct their own investigation pertaining to any allegations related to my claim of psychological injury. This authorization shall become effective on Date and will expire in one year. A photocopy of facsimile of this form is to be considered as valid as the original.I understand this authorization for release of information is non-revocable.I have read this consent form in it's entirety, have been given the opportunity to ask questions and clarify any issues that may not be clear, and fully understand its content.