AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
Patient’s Name
Date of Birth

MonthDayYear
Date
I hereby authorize Blue Sky MD Health and its employees to release or obtain (check appropriate box) information pertaining to my medical care and treatment, including, but not limited to, mental health records, drug and alcohol abuse records, and diagnosis and/or treatment of HIV (Aids Virus).
(check appropriate box)

Yes, Blue Sky MD Health may release my information.Yes, Blue Sky MD Health may obtain my information.
Release to:
Obtain from:
I understand that I may revoke this consent at any time, and that upon fulfillment of the above-stated purpose or lapse of 12 months from the date of signature, whichever comes first, this consent will automatically expire without my express revocation, but that revocation may not be applied retroactively once the information has been released in good faith. I understand Blue Sky MD Health and its staff cannot be responsible for confidentiality of information disclosed after said information has been released pursuant to this authorization, and I hereby release them from any liability arising from such disclosure and from all legal responsibility or liability that may arise from this authorization.
Signed

Clear
Date

MonthDayYear
Date
Witness

Clear
Date

MonthDayYear
Date
If not signed by the patient, please indicate relationship:

Parent or Guardian of minor patientGuardian or conservator of an incompetent patientBeneficiary or personal representative of deceased patient
Blue Sky MD, PC
Dr. David LaMond NPI- 1942298237
317 N. King Street, Hendersonville, NC 28792 | Fax: 828.693.3344 | Office: 828.692.2487
111 Central Street, Sylva, NC 28779 | Fax: 855.308.2340 | Office: 828.586.7705
Should be Empty: