Request for INFORMATION I hereby request the release of Protected Health Information (PHI) and/or information in your possession to Centennial Consulting and Associates LLC, Charles 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 |