Release of Information

Release of Information
Columbus Behavioral Health
An Association of Independent Practitioners

614.360.2600
Dublin | Westerville
AUTHORIZATION FOR THE RELEASE OF PROTECTED HEALTH INFORMATION

None of the information or records obtained under this authorization may be re-released.
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Phone Number*

Area CodePhone Number
I, (name),*
Patient name
hereby authorize my provider at CBH*
Name of therapist or CNP you see at COLUMBUS BEHAVIORAL HEALTH
and/or Columbus Behavioral Health and its representatives acting on behalf of my provider,

Located at:

115 Commerce Park Drive
Westerville, OH 43082

or

6265 Riverside Drive, Ste 1S
Dublin, OH 43017

to:
SELECT ONE*

RELEASE information TORECEIVE information FROMEXCHANGE information WITH
Name of entity receiving information*
Please enter the name of the person/physician/office/school/therapist, etc. information should be released to/from. Do NOT put client name here and do NOT put CBH provider name here.
Receiving entity's address (NOT PATIENT'S ADDRESS)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Receiving entity's phone number (NOT PATIENT'S PHONE)*

Area CodePhone Number
Receiving entity's fax number*

Area CodePhone Number
PURPOSE OF RELEASE (check all that apply)*

At the request of the individualContinuity of careInsuranceLegal reasonsPersonal useDisability/leave of absence claimOther
What dates of service are to be included?*

ALL dates of service (full record)Only service dates specified below
If only specific dates of service are to be released, please indicate those dates here:
Information to be disclosed*

FULL recordONLY the information selected below
Do not release full record. ONLY release the following information:

AssessmentDiagnosisProgress/appointment notesMedicationsOther
This authorization shall remain in effect until:*

Patient (or parent/guardian, if minor) revokes it (in writing)One year from date signedOther
This authorization will remain in effect until revoked or shall expire on date or event specified below. I understand that I may revoke or cancel this authorization at any time by submitting written revocation to:

Columbus Behavioral Health
ATTN Privacy and Security Officer
115 Commerce Park Drive
Westerville, OH 43082

except to the extent that action has been taken in reliance on this authorization. If this authorization has not been revoked, it will expire on the date or completion of the event stated below. If no date or event is specified below, this authorization will expire in one year.

You may refuse to sign this authorization and Columbus Behavioral Health may not condition treatment, payment, and enrollment, or eligibility for benefits on signing this authorization I understand that information disclosed by this authorization, except as prohibited by 42 CFR Part 2 or other applicable law, may be subject to re-disclosure by the recipient and may no longer be protected by the Health Insurance Portability and Accountability Act Privacy Rule (45 CFR Part 164].
Expiration date/event. If no date or event is specified below, this authorization will expire one year from date signed.
Printed name*

First NameLast Name
Signature (patient or legal representative)*

Clear
Date*

MonthDayYear
Date
Relationship to patient*

Self (patient)ParentLegal guardianHealthcare power of attorneyExecutor/Adminstrator
Should be Empty: