Form – Authorization to Release Information

Please complete this form for authorization to release information to a specific individual. For example a spouse, family member, significant other, doctor, etc.

Please complete the information below to acknowledge.

I, hereby acknowledge that I have read and understand the policies of Blue Sky Health and Wellness.
Please enter individual's name here (for example: spouse, family member, significant other, doctor, etc.)
PLEASE SIGN HERE FOR YOUR E-SIGNATURE.
MM slash DD slash YYYY

Please do not submit any Protected Health Information (PHI).

This field is for validation purposes and should be left unchanged.

Please do not submit any Protected Health Information (PHI).