Records Request

Columbus Behavioral Health
An Association of Independent Practitioners

CONFIDENTIAL RECORDS REQUEST

The patient, or patient's representative, may obtain a copy of the records by completing this records request/release form. The records will be provided within 7-10 business days after receipt of this written request. One set of records is provided in a 12 month period without a fee. We reserve the right to charge for additional requests for records in any 12 month period.

AUTHORIZATION FOR THE RELEASE OF PROTECTED HEALTH INFORMATION

Records released pursuant to this authorization may include information concerning testing, diagnosis or treatment of HIV/AIDS, psychiatric and/ or drug/alcohol treatment, and/or sexual assault.
SECTION I: Requestor's Information
Name of person requesting records
First NameLast Name
Requestor is
the patientthe patient's personal representative
If personal representative, relationship to patient (Columbus Behavioral Health may request additional information to establish proof of authority)
N/A- PATIENT is requestingParentLegal guardianHealthcare power of attorneyExecutor/administrator
Requestor's phone number
Area CodePhone Number
Requestor's address
Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Requestor's email
example@example.com
Identity verification: By law, reasonable steps must be taken to establish the identiy of the person requesting to obtain a copy of the patient's records. Failure to provide this identifying information may result in denial of this request. Please use the widget below to take a picture your unexpired photo ID (driver's license, passport, or state issued ID card).
Take Photo of your Picture ID *
SECTION II: Patient Information
Patient's Name
First NameLast Name
Patient's Date of Birth
MonthDayYear
Date
Patient's address
Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SECTION III: Recipient and disclosure information

I hereby request and authorize the disclosing entity (my provider(s), Columbus Behavioral Health and its representatives), to release information to:
Recipient (release records to this person/entity)
Format delivery of records*

Electronic to email belowFax to number belowPaper mailed to the address belowSend through patient portal (message)
Recipient's email address (IF records are to be emailed)
example@example.com
Recipient's fax number (IF records are to be faxed)
Area CodePhone Number
Recipient's address (IF records are to be mailed)
Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PURPOSE of release (check all that apply)*

At the request of the individualContinuity of careInsuranceLegal reasonsPersonal useDisability/leave of absenceOther
Information to be released*

Release ALL information/FULL RECORDONLY release the information indicated below
Release ONLY the following information
DO NOT ANSWER this questions if you selected ALL information/FULL RECORD above as all information will released. If you only what certain information released choose ONLY RELEASE INFORMATION to the question above and then select items here.
Assessment notesTherapy progress/appointment notesMedication management progress/appointment notesList of medications last prescribedDiagnosisOther
Please provide any special instructions, if necessary, about what you want included or not included (only a specific provider, all providers, test results, etc)
Time frame*

All dates of serviceOnly records for date(s) specified below
If specific dates requested, start date m/d/year end datem/d/year .
Section IV: Authorization

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].

Denial of request. If the disclosing entity determines that disclosure of the full records is reasonably likely to cause substantial harm to the patient or another individual, this request may be denied. If denied, the requestor will be notified in writing via email within 7-10 days of the request with the reason for denial and may choose to receive a treatment summary instead of full notes; may meet with a therapist to review the contents of the records; or can have the records sent to a mental health provider or physician they designate.
This authorization shall remain in effect until
RevokedOne yearEvent listed below
Event (if applicable)
Signature of patient (or personal representative identified above)
Clear
Date
MonthDayYear
Date
Should be Empty: