Blue Sky - Authorization Form

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

Month Day Year
Date
I hereby authorize Blue Sky MD and its employees to release or obtain (check the appropriate box below) I hereby authorize Blue Sky MD and its employees to 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).
Authorization *

Release Obtain
Release To:
Obtain From:
Release To:
Obtain From:
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. | understand Blue Sky MD 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

Month Day Year
Date
Witness
Date

Month Day Year
Date
If not signed by the patient, please indicate relationship

Parent or Guardian of minor patient Guardian or conservator of an incompetent patient Beneficiary or personal representative of deceased patient
Blue Sky MD

New Patient Established Patient
10616 Metromont Pkwy, Unit 210, Charlotte, NC 28269704.774.6569 1998 Hendersonville Rd, Unit 51, Asheville, NC 28803828.651.0450 317 North King Street, Hendersonville, NC 28792 |828.693.9199 1287 Creekshire Way, Winston Salem, NC 27103|336.245.9521 307-J Pisgah Church Road, Greensboro, NC 27455 |336.252.3993
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AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION