Brenda S Allen

• Conway Regional Health System
• 2302 College Ave
• ATTN: MEDICAL RECORDS
• Conway, AR. 72034
• Office: 501-450-2130
• Fax: 501-450-2130
• Brenda S Allen
• 10/21/1956
• Patient's Name
• Date of Birth
• 664 Bradley Road 33
• Hermitage
• AR
• 71647
• Medical Record Number
• Itried75@gmail.com
• Address
• City
• State
• Zip
• Telephone Number
• Email Address
• I authorize the use and disclosure of health information about me as described below:
• Conway Regional Imaging Center: 555 Club Ln.
• Facility Authorized to Release my Health Information
• Brenda Allen - eDelivery to: itried75@gmail.com
• Agency or Individual(s) Authorized to Receive my Health Information
• Health information that may be used / disclosed is limited to the following:
• Discharge Summary
• History & Physical
• Consultation(s)
• Lab
• Operative Note(s)
• Imaging/Radiology
• Radiology
• Progress Notes
• Emergency Room Record
• Pathology Report
• Entire Record
• Other (specify) mammogram records
• Health information that may be used / disclosed is limited to the following periods of healthcare:
• From (date): 01/01/2015
• To (date): 05/04/2026
• Account Number:
• From (date):
• To (date):
• Health information to be released to the above named agency/individual is to be used/disclosed for the following purpose(s):
• Treatment/Consultation
• At Request of Patient
• Research
• Marketing
• Billing or Claims Payment
• At Request of Employer
• Other
• "Health Information" identifies you (the patient) by name and includes other demographic information about you. "Health Information" may include, but is not limited to: medical records, X-Ray films, slides, tracings, strips, etc.
• I hereby discharge the releasing facility, it's agents, and employees from any and all liabilities, responsibilities, damages, and claims which might arise from the release of information authorized herein, to include alcohol, drug abuse, communicable disease including HIV status, and/or psychiatric diagnoses compiled during my visit, encounter or hospitalization, or make copies thereof in accordance with the policies of this facility.
• Yes
• No if applicable I agree to the release of my medical or billing records containing sensitive information listed above.
• Protected Health Information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and is no longer protected by this privacy rule. If re-released Health Information is used or disclosed for continued research purposes, an expiration date or event does not apply.
• This authorization will automatically expire 180 days after the date of signature below (except as indicated below), unless an earlier date is specified, or at the conclusion of a specified event. I understand that I have a right to revoke this authorization at any time, in writing, as stated in the Notice of Privacy Practices, except where the facility has already made disclosures in reliance upon my prior authorization.
• Treatment, payment, enrollment or eligibility for benefits may not be conditioned on obtaining an authorization if the HIPAA prohibits such conditioning. If conditioning is permitted, refusal to sign the authorization may result in denial of care or coverage.
• Copy to the individual: If a covered entity seeks an authorization from an individual for a use or disclosure of protected health information, the covered entity must provide the individual with a copy of the signed authorization.
• NOTICE TO RECEIVING AGENCY OR INDIVIDUAL: This information is to be treated in accordance with (HIPAA) privacy regulations.
• Patient's or Authorized Personal Representative's Signature
• Brenda Allen
• Date
• 05/04/2026
• Time
• 10:30 am
• Relationship to Patient/Authority to Act on Patient's Behalf
• Interpreter, If Used
• Expiration Date or Event
• For Medical Records Use Only
• Signature validated against driver's license or signature in Medical Record. There may be a charge for copying Medical Records.
• Electronic copy requested.
• Revised 10/2020 HIPAA Release of PHI
• Page 1 of 1

• Brenda Allen (D.O.B. 10/21/1956)
• 1. Driver's License
• 2. Mailing Address
• 664 Bradley Road 33
• Hermitage, AR 71647
• 3. Email Address (user confirmed)
• Itried75@gmail.com (consented to an emailed copy of their request)
• 4. Phone Number (verified)
• (479) 653-5115
• 5. Requestor Signature
• Brenda Allen
• REASON FOR REQUEST
• Continued Care
• REQUEST SPECIFIC COMMENTS
• Mammogram records please

• Datavant
• SENT
• 05/04/2026
• 10:30:31 GMT-04:00
• Sent for signature to Brenda Allen
• (itried75@gmail.com)
• VIEWED
• 10:30:33 GMT-04:00
• Viewed by Brenda Allen (itried75@gmail.com)
• IP: 67.14.193.112
• SIGNED
• 10:30:55 GMT-04:00
• Signed by Brenda Allen (itried75@gmail.com)
• COMPLETED
• 10:30:57 GMT-04:00
• The document has been completed. (Request ID: JRJGIKS4)

I worked at Walmart off and on after my husband and I were pastoring full time. Mostly seasonal but always same position with opportunity to stay with Walmart.

I’m older than most but my work ethic plus desire to work and be with the public is stronger than most of the younger generation. We have opportunities to teach them by example.

My Motto is. Significant finances in life is not SUCCESS.

Being Significant in life is SUCCESS.