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. There is no fee for processing record requests.

AUTHORIZATION TO RELEASE 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)*

ParentLegal guardianHealthcare power of attorneyExecutor/administratorN/A- patient making request
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 disclose health information about the above named patient as follows:
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
Reason for disclosure*
(continuity of care, personal use, etc)
Information to be released (check all that apply)*

Whole recordAssessmentProgress notesMedication management informationDiagnosisTreatment summaryOther
If other, explain
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 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 disclosure 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].

Denial of request. I understand that 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, I (the requestor) will be notified in writing via email within 7-10 days of the request with the reason for denial and I may choose to receive a treatment summary instead of full notes; I may meet with a therapist to review the contents of the records; or I can have the records sent to a mental health provider or physician that I 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: