Online Patient Registration Application

Uses and Disclosures for Treatment, Payment, and Health Care Operations

Clinicians and administrative staff of Commonwealth Behavioral Health (CBH) follow the Health Information Portability and Privacy Act (HIPPA). Clinicians and administrative staff of CBH may use or disclose your protected health information for treatment, payment, and health care operations purposes with your consent only. We do not share your information with any other sources unless you sign a release of information.

Click Here for a Printable Application [pdf]

Note: All fields are required. If a field does not apply, please write "n/a".

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Medical Information

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