ADULT – PERMISSION TO RELEASE INFORMATION

Who is your provider?*
Client Legal Name
First Last
Client Preferred Name
First Last
Date of Birth
Month
Day
Year
I hereby give my permission for the release and/or exchange of pertinent medical, psychological, personal, drug and alcohol, and/or educational records between INSIGHTS GROUP and the following person(s) or agencies for the purpose of treatment coordination:
PHYSICIAN
Address
Street Address Address Line 2 City State ZIP Code
Phone
Email
DIETITIAN

Please note: If you are receiving therapy to treat an eating disorder, it is required that you simultaneously work with a dietitian. If you do not yet have one, a referral list can be provided to you with the expectation of having a dietitian in place within the first two months of therapy.
Address
Street Address Address Line 2 City State ZIP Code
Phone
Email
PRIOR THERAPISTS
Address
Street Address Address Line 2 City State ZIP Code
Phone
Email
OTHER PROFESSIONALS
Address
Street Address Address Line 2 City State ZIP Code
Phone
Email
CONTACTS
Address
Street Address Address Line 2 City State ZIP Code
Phone
Email
RECORDS MAY BE SHARED BY (check acceptable means)
- VERBAL
- WRITTEN
- FAX
- EMAIL
PLEASE CHECK THE BOX WHICH REFLECTS YOUR DECISION AND THEN SIGN BELOW
- I give my permission for the release/exchange of information described above.
- I give my permission for the release/exchange of information described above with the exceptions given below:
Exceptions
Signature*
Date*
MM slash DD slash YYYY

Please wait for the confirmation before closing out of the form.

NOTICE TO THE PERSON[S]/AGENCIES/OTHER[S] FROM WHOM RECORDS ARE BEING REQUESTED
All records received by Insights Group will be available for inspection by the parent, legal guardian, surrogate parent, or adult student. Records will be re-released upon receipt of written permission from the patient.