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

Request for INFORMATION

 

I hereby request the release of Protected Health Information (PHI) and/or information in your possession to Centennial Consulting and Associates LLCCharles G. Allen, Ph.D. and additional parties named herein.

This request is not for specific or detailed information or private notes regarding treatment or therapy, which in your judgment, would bring harm to myself or any member of my family.  I am not requesting that you release any information which is beyond the scope of this request.

I request the delivery of this information via telephone, HIPAA compliant/encrypted email, or postal mail, and for security reasons, I do not authorize the delivery any PHI by facsimile.

An electronic email or photocopy of this authorization shall have the same force and effect as an original.  I understand that I may revoke this request at any time either verbally or in writing except to the extent that action has already been taken to comply with this release.  This request automatically will expire in six (6) months from the date of signature below or upon fulfillment of this request.

Date of Request: March 28, 2024

 

First Patient's Name

First Name*

Middle Name

Last Name*

Phone*
First Patient's Date of Birth*
First Patient's Signature*
Patient's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
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 request the following Agency or Individual release PHI information and Records per instructions below to Centennial Consulting and Associates, LLC.

PHI and Records may ALSO be released to:

Agency or Individual(s) to release my PHI: *
Specific Information to be released: *
Initial Evaluation and Assessment
All Psychiatric Diagnosis
Treatment/Discharge Summary
Other (see below)

Other Information Requested:
Parent(s) or court-appointed legal guardian(s) must sign for any participating 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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