Patient Medical Records Requests

The privacy and confidentiality of our patient’s personal health information is very important to us.

Did you know you may access your records through the Patient Portal by clicking here? Or you can request a copy just follow the directions below.

To ensure complete and timely processing of your request please follow the directions below.

The patient or patient’s legal guardian will complete the Request Form. Click here to download.
Fill out the entire form, complete it and return the form to Centennial Health by one of the following methods:
- Personal Delivery to any one of the Centennial Health Clinics
- Mail to:
  Centennial Health
  ATTN: Medical Records
  PO BOX 1770
  Edmond, 73083

Do you have a question about a request you made? Please contact Medical Records processing center at:

DataFile Contact

To request an amendment to your medical record or make changes to who you share your information with contact the Compliance Officer at

Phone: (405) 330-7003
Email: Compliance@centennialhealth.com
Address:
ATTN: Heidi Delaney
Centennial Health
225 Lilac Drive, Suite 200
Edmond, OK 73034

25%

What Records do you want? (Complete the respective section)
1. Date(s) of Service
through
Provider
2. Specific Problem or Diagnosis
3. Other (Vaccination Record, Lab Work, Entire Chart)
* My medical information may indicate that I have a communicable and/or non-communicable disease which may include, but is not limited to diseases such as hepatitis, syphilis, gonorrhea, or HIV or AIDS and/or may indicate that I have or have been treated for psychological or psychiatric conditions or substance abuse.
* This release is valid only for the services I have indicated. I have the right to revoke this request at any time prior to the actual release of records.
* I understand that Centennial Health is not responsible for the use or disclosure of the records after they have been released to the designated person or Organization.

Where do you want the information sent? (Fill in all information below)
I am requesting the above noted records be released to
- Me
- Person/Organization Specified Below
Person or Organization to receive records
Recipient Phone Number
Recipient Fax Number (Healthcare Provider Only)
Address
Street Address City State / Province / Region ZIP / Postal Code
If you are picking up your records, please indicate which location you will pick them up at:
- Downtown
- Midwest City
- Edmond
- I am out of the area and will pay postage for records to be mailed to me at my address above.
*There may be charges associated with processing a request and producing requested records pursuant to 45 CFR164.524(c)(4)

I understand that checking the box below constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.*
- I Agree
Print Name*
Relationship to Patient
Date*