Forms & Privacy Practices

Patient Forms

If you wish to have a copy of your medical records released to another party, please complete the Authorization Form below and bring it to our office: 

►Authorization for Disclosure of Protected Health Information

If you are a new patient, please print and complete the following forms and bring them with you to your first visit:

►Pediatric Consent Form

►Adult Consent Form

►Health History Form

For sports physicals, please print and complete the following form and bring it with you to your child's visit:

►OHSAA Sport Pre-Participation Physical Evaluation Form

Privacy Practices

If you wish to learn more about Columbiana Family Care Center’s privacy practices, including how your medical information may be used and disclosed and how you can get access to this information, Click Here to read our Notice of Privacy Practices.