Release of Information

Release of Information
Columbus Behavioral Health
An Association of Independent Practitioners

614.360.2600
Dublin | Westerville | New Albany
AUTHORIZATION TO OBTAIN OR RELEASE INFORMATION

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

First NameLast Name
Client Date of Birth*

MonthDayYear
Date
I, (name),*
Patient name
hereby authorize my provider*
Name of your therapist or nurse practitioner
and/or Columbus Behavioral Health and its representatives acting on behalf of my provider,

Located at:

124 County Line Road West, Suite B
Westerville, OH 43082

or

5071 Forest Drive SteB
New Albany, OH 43054

or

6265 Riverside Drive, Ste 1S
Dublin, OH 43017

to:
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
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
Information is to be released for purpose of:*
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:

Confirmation of participation on therapyDiagnosisAssessmentProgress notesPsychotherapy notesTreatment summary letterPsychological testing resultsLab resultsMedicationsBehavior rating scalesOther
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 in the manner specified by the disclosing entity, 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 If this authorization has not been revoked, it will expire on the date or completion of the event stated below.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.

I understand that I may not be denied treatment, payment, and enrollment in the health plan, or eligibility for benefits for refusing to authorize disclosur e unless such denial is permitted under state and federal law.
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: