Referral Packet

Using the referral packet, you will find links to forms and notices for the counties we serve. These counties we support include Allegany, Cattaraugus, Cayuga, Chautauqua, Chemung, Erie, Genesee, Livingston, Monroe, Niagara, Ontario, Orleans, Schuyler, Seneca, Steuben, Wayne, Wyoming, and Yates.

All individuals will need to read the HIPAA Notice of Privacy Practices and sign an Authorization for Release of PHI and Acknowledgement of Notices and Privacy Practices. Please save these items and open them using Adobe Reader or a similar product. Continue scrolling for additional information.

Versions of Required Forms [Spanish Version]

Consent Form Completion

Please watch the video provided for more information on consent form completion.

Once the forms are completed and signed, they can be emailed directly to intake@personcenteredservices.com or faxed to (716) 671-2175. They can also be sent, along with a self-addressed stamped envelope to Person Centered Services, Intake Dept., 1090A Union Road, Suite 260, W. Seneca, NY 14224.

Upon receipt of the information requested an Intake Specialist will reach out and begin assisting you with the intake and enrollment process.

A slide featuring the Person Centered Services logo with a banner reading Celebrating 5 years. Text reads: Consent Form Updates Starting August 7, 2023. Two people are smiling and looking at papers together.

Required Forms

Please fill out and submit the following forms:

Intake Cover Letter
Referral Form
HIPAA Notice of Privacy Practices
Acknowledgement of Notices and Privacy Practices
Authorization for Release of PHI
Blank Authorization for Release of PHI (For Additional Providers)

You can reference the sample examples below for filling out acknowledgments and authorizations:

Acknowledgement of Notices and Privacy Practices Sample Example – Authorization for Release of PHI