Fillable 50-173 Rev. 04/19

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50-173 Rev. 04/19

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50-173
Rev. 04/19
Pathways, Inc. • P.O. Box790 • Ashland, KY 41105-0790
AUTHORIZATION FOR RELEASE OF INFORMATION
1. The undersigned hereby request and/or authorize:
to release the medical record of:
Name:
SS# - -
Birth Date: / /
Dates of Professional Service:
Address:
Phone:
YES
NO
INFORMATION
AUTHORIZED TO RELEASE
INITIALS
YES
NO
INFORMATION
AUTHORIZED TO RELEASE
INITIALS
Major Evaluations
Medications
Treatment Plans
Progress Notes
Appointment History
Other:
Doctor Notes
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 date of signature or the following 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 Signature of Client/Resident/Patient
_________________________________________________ __________________________________________________________________________________
Witness Signature of Client’s/Resident’s/Patient’s Agent or Representative
This form must contain original signatures. Relationship: ________________________________________________________________
Address: ______________________________________________________________________
City: ________________________ State: __________________ Zip: __________________
COMPLETE BELOW ONLY IF THE CONSUMER WISHES TO REVOKE ABOVE AUTHORIZATION
I, _____________________________________________________________________ wish to revoke this authorization.
_________________________________________________ __________________________________________________________________________________
Date Signature of Consumer, Guardian, or Authorized Representative
_________________________________________________ __________________________________________________________________________________
Date Pathways, Inc. Witness
Birth Date: / /
SS# - -
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50-173
Rev. 04/19
Pathways, Inc. • P.O. Box790 • Ashland, KY 41105-0790
ADDENDUM A
2. Information to be released to (Continued): Unless you are providing treatment to the client, you must specify name of
an individual NOT a law firm, court, office, etc.
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50-173 Rev. 0419

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Completed 20 April 2021

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