Client confidentiality is of paramount importance at Portage Path, and the services provided at Portage Path Behavioral Health are governed by strict federal and state laws regarding client confidentiality. Violation of these laws can lead to serious fines, penalties, and sanctions against our organization, as well as compromise our ability to create and maintain trust with our clients.
Other than through a court order, the ONLY way we can release ANY information about a client is for the client to complete and sign a Release of Information Form. All uses and disclosures of Patient Health Information (PHI) will be in strict compliance with the Minimum Necessary Policy (as outlined in HIPAA) and any agreed upon release restrictions.
You can use the link below to download a copy of our Release of Information Form. Please consult the instructions below to make sure the release is completed correctly.
How to Fill Out the Release
The Authorization for Release of Information Form has a number of critical areas that must be completed in order for a Release to be valid. These areas are:
From The Records Of: This area must, at a minimum, include the client’s first and last name, current date when release is executed, full date of birth, and Social Security Number. Accurate submission of this information will eliminate the possibility of error on our part when providing information.
I Authorize Portage Path Behavioral Health To: It is extremely important that this section of the Release be completed because this is the section where the client tells us who we can talk to. Blanket Releases, those that do not identify a specific individual or facility are not valid and will not be accepted. Therefore, make sure you or the client check the Release to box, then provide us with the name, address, and telephone number of the person or facility that you would like the information directed to.
I Authorize The Release Of The Following Information BY Portage Path Behavioral Health: Again, this is a very important section to complete on the Release form. Remember that PPBH operates on the Minimum Necessary (Health Information) policy. If you or the client do not designate the type of information you would like communicated, it is likely that none will be forthcoming. Please check all information of interest and also identify the Release Format (verbal or written.)
I Authorize The Release Of The Following Information TO Portage Path Behavioral Health: As a referral source, there may be information that you want to communicate to us regarding your experience or records regarding the client. Please check off any information in this section that you would like the client to authorize for release to us.
Specific Purpose/ Need For Information: You must identify a specific purpose or need for this information in order to make the Release valid. Examples of this might be “Court-Ordered Follow-Up,” “Initiation of New Treatment,” or “Benefit Eligibility Determination.”
This Release Will Expire In 180 Days Unless Otherwise Specified: There are a number of options for determining when a Release will expire, starting at 90 days and extending through the length of treatment. In order to accommodate your needs as a referral source, we recommend that the client check the “Length of Treatment” box on the form. This will authorize communication until such time as the client finishes treatment or revokes the Authorization.
Signature Section: A valid Release of Information form must be signed and dated by the client as well as signed and dated by a witness, you the referral source, can act as the witness.
Once The Form Is Completed: Once the form is completed, the ORIGINAL Release form must be returned to our office. For ease of processing, please send the original to:
Director, Clinical Information and Record Services
Portage Path Behavioral Health
340 South Broadway
Akron, OH 44308
Having the Client Complete the Form in Your Office or Completing the Form Later:
If possible, it will always be better to have the client complete the Authorization for Release of Information form in your office. The Release, along with the Client Referral Form can then be sent to our offices and authorize communication at the outset of treatment. Otherwise clients often times indicate a willingness to authorize communication while in your office, but change their mind when they present to us. At that time, their choice to not authorize communication will be honored and no information will be provided to you.