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Get Trillium Health Resources Consent For Release Of Member Information 2017-2024

Ative Calls - 866.998.2597 TrilliumHealthResources.org CONSENT FOR RELEASE OF MEMBER INFORMATION Member Name Member DOB Member Record # Member Social Security Number: (Optional) This authorization form implements the requirements for member authorization to use and disclose health information protected by: Federal Health Privacy Law, 45 CFR Parts 160, 164 Federal Drug and Alcohol Confidentiality Law, 42 CFR, Part 2 North Carolina State Confidentiality Law governing mental health.

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