• Release of Information

  • Columbus Behavioral Health
    An Association of Independent Practitioners

    614.360.2600
    Westerville | New Albany

  • AUTHORIZATION TO OBTAIN OR RELEASE INFORMATION

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

  •  - -
    Pick a Date
  • 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

    5071 Forest Drive SteB
    New Albany, OH 43054

    and via telehealth

     

     

    to:

     

  •  -
  •  -


  • 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 If this authorization has not been revoked, it will expire on the date or completion of the event stated below.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].

     

  • Clear
  •  - -
    Pick a Date
  • Should be Empty: