For more information:

(603) 247-4191 / drrobin@insightsgroup.net

1245 Washington Road

Rye, New Hampshire 03870

For more information:

(603) 247-4191 / drrobin@insightsgroup.net

1245 Washington Road

Rye, New Hampshire 03870

MINOR  – PERMISSION TO RELEASE INFORMATION

  • I hereby give my permission for the release and/or exchange of pertinent medical, psychological, drug and alcohol, and/or educational records between INSIGHTS GROUP and the following person(s) or agencies for the purpose of treatment coordination:
  • Date Format: MM slash DD slash YYYY

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.

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