Consent for Care and PHI Release | Centennial Primary Care

After filling out this form, use the Print button at the bottom to print it. Bring the printed form to our office.

Care and treatment

As the patient or patient’s representative, I hereby consent to necessary examination, procedures or treatment as prescribed by my physician or her assistants. I understand that I am under the care and supervision of my attending physician.

Consent to release protected health information (PHI)

I understand that my healthcare information at Centennial Primary Care is protected. I also understand that in order to disclose my PHI, Centennial Primary Care must have my consent. Therefore, I authorize Centennial Primary Care to disclose my PHI as described in this form, to the persons listed below:

Information to discloseOther information to discloseAuthorized person 1 — nameAuthorized person 1 — phoneAuthorized person 1 — relationshipAuthorized person 2 — nameAuthorized person 2 — phoneAuthorized person 2 — relationship

Contact preferencesHome phoneCell phoneWork phoneMay we leave a detailed voicemail?

Initial only if opting out

I DO NOT authorize Centennial Primary Care to release my PHI to anyone other than myself. I fully understand that by doing so it may take longer to get my results.

Patient receipt of Notice of Privacy Practices

CENTENNIAL PRIMARY CARE has provided information regarding the Notice of Privacy Practices. This notice describes the practice’s commitment to privacy, my rights to privacy, and how Centennial Primary Care may use and disclose protected health information (PHI) about me to carry out treatment, billing and healthcare operations.

By signing this form, I acknowledge that I have reviewed the Notice of Privacy Practices and understand how my information will be used and disclosed. I understand that I am entitled to receive a copy of this document upon request.

Signature of patient or representative

Date