Form – Authorization to Release Information InstagramThis field is for validation purposes and should be left unchanged. 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).CAPTCHA Please do not submit any Protected Health Information (PHI).
