Authorization for Release of Information
50-173 Rev. 10/22
Are you:
New - Completing the Authorization for Release of Information for the first time
Updating - Completing the Annual Update or Updating a previously completed Authorization for Release of Information
If Updating, please select the service location the Authorization for Release of Information should be returned to:
Bath County
Boyd County - 22nd Street/Substance Use Disorder
Boyd County - Lansdowne/Mental Health
The undersigned hereby request and/or authorize:
To release the medical record of:
First Name
Middle Name
Last Name
Social Security Number
00-000-0000
Date of Birth
-
Month
-
Day
Year
Date
Dates of Professional Services
Ex: 02/2022 - 10/22
Submit
Should be Empty: