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Centennial Consulting and Associates, LLC
Charles G. Allen, Ph.D.
Licensed Psychologist #1372

AUTHORIZATION FOR RELEASE OF INFORMATION

In order to establish an alliance, it is essential that the Therapeutic Relationship is understood as sacrosanct.  A patient MUST trust that what they reveal in psychotherapy will NEVER be disclosed without their written consent.  The following Authorization for the Release of Information is based upon the Biomedical Ethical Principals of:  Respect for Autonomy, Beneficence, Non-Maleficence, and Justice.

 

I do hereby authorize any Associate of Centennial Consulting & Associates, LLC to release only Mental Health records or Protected Health Information (PHI) in their possession; which in their judgment is deemed appropriate and in my best interest.  I do hereby consent and release from all liability any Associate of Centennial Consulting & Associates, LLC who must release any information required by law to anyone or any agency if in that Associate's judgment; as a result of a mental disorder, I am a Danger to Myself, a Danger to Others or Gravely Disabled or if this is a matter of Child or Elder Welfare.  I understand that Associates of Centennial Consulting & Associates do not need my consent to Release Information required by law.  I authorize the delivery of this information verbally, in person, telephone, HIPAA compliant/encrypted email, or postal mail.  All information that is released will be copied to me via email.

Restrictions:

All Requests for Information must be in writing and specific in nature.

  • I do not authorize the release of ANY and ALL records
  • I do not authorize delivery by facsimile (fax)​
  • I do not authorize the release of any information to an agency or company, without the identification of specific individual(s)
  • I do not authorize the release of any information supplied to Centennial Consulting & Associates, LLC by a third party
  • I do not authorize the release of any detailed information or private notes regarding my treatment or psychotherapy, that could bring harm to me or any family member
  • I do not authorize the release of any information which is beyond the scope of the request initiating this Release

 

I understand that I may revoke this authorization at any time either verbally or in writing except to the extent that action has already been taken to comply with this release. Without my express revocation, this authorization will expire in six (6) months from the date of signature below. This authorization will automatically expire upon completion of this request or at the conclusion of treatment.


Date Signed: April 25, 2024

The information released herein is for:
AdultMinor
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First Client Name

First Name*

Middle Name

Last Name*

Phone*
First Client Date of Birth*
First Client Signature*
Parent or Guardian's Email Address

Email*

Confirm Email*
Parent or Guardian's Driver's License / ID Card

Driver's License / ID Card Number*

Issuing State*
I hereby Authorize the Release of the following:
Details *
Specific questions or documents submitted by the requesting agency or individual.

ANY additional information to be released:
My information will be released to:*
- My Insurance Carrier
- My Attorney (including Law Firm)
- Another Mental Health Provider
- Other (listed below)
I authorize the release of information to the following Agency and/or Individual(s). I do not authorize the release of information to an agency alone, it must identify the specific person(s).

Name of Agency requesting information:

Name of the individual(s) AND email address that I wish to receive this information: *
Parent(s) or court-appointed legal guardian(s) must sign for any minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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