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.Name of the Signatory(Required)I, hereby acknowledge that I have read and understand the policies of Blue Sky Health and Wellness. Phone(Required)Email(Required) I give my permission to the doctors of Blue Sky Health and Wellness, LLC., to discuss or obtain information regarding my treatment to:(Required)Please enter individual's name here (for example: spouse, family member, significant other, doctor, etc.)Signature(Required)PLEASE SIGN HERE FOR YOUR E-SIGNATURE.Date Signed(Required) MM slash DD slash YYYY Please do not submit any Protected Health Information (PHI).CAPTCHANameThis field is for validation purposes and should be left unchanged. Please do not submit any Protected Health Information (PHI).