Authorization For Release of Information

Authorization For Release of Information

50-173 Rev. 7/24
1. The undersigned hereby request and/or authorize:*
to release the medical record of:
Name*

First NameLast Name
Social Security Number*
000-00-0000
Birth Date*

MonthDayYear
Date of Professional Service*

MonthDayYear
2. Information to be released to:*
Address*

Street Address

Phone Number

CityState / Province

Postal / Zip Code

3. Information to be released - check yes or no AND initial (may include substance use disorder records, if applicable).*

If other:
4. Purpose of release:*
Time limitation of Release: This consent is subject to revocation at any time, providing the information has not already been disclosed. Please see our Notice of Privacy Practices for instructions as to how to revoke this authorization.
This authorization expires one year from the date of the signature Date or Event (not to exceed one year).
Prohibition on redisclosure: This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 2 and 45 CFR Parts 160 and 164) and/or KY state law. The Federal rules and/or KY state law prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2 and/or KY state law. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse client.
Date

MonthDayYear
Signature of Client/Resident/Patient

Clear
Witness

First NameLast Name
Signature of Client's/Resident's/Patient's Agent or Representative

Clear
This form must contain original signatures.
Relationship:

Street Address

CityState / Province

Postal / Zip Code
Pathways, Inc., P.O. Box 790, Ashland, KY 41105-0790
Should be Empty: