Get Trillium Health Resources Consent For Release Of Member Information 2020-2025

Filling out the Trillium Health Resources Consent For Release Of Member Information is an essential step in ensuring that your health records are shared appropriately. This guide will provide you with clear, step-by-step instructions to complete the form online effectively.

Follow the steps to complete the consent form online successfully.

1. Click the ‘Get Form’ button to access the consent form and open it in your preferred editing platform.
2. Enter the enrollee’s full name, including any maiden or previous names. Make sure to add their date of birth and social security number if available.
3. If the member is present and requesting the records, they should write their name in the statement: 'I, ___________hereby request and authorize…'. If you are the provider, write your practice name and your own name.
4. Specify the name of the organization or provider from which the records will be obtained. For example, use names like Southeastern Center or Roanoke/Chowan Human Services Center.
5. List the name of the organization or individual where you wish to send the records. Include the full address and fax number.
6. Clearly indicate which specific records you would like to receive, such as a medication list or psychological evaluations.
7. State the purpose for accessing these records, such as for care and treatment.
8. Indicate an expiration date for the request, typically one year from the date of signing, unless specified otherwise.
9. Sign and date the form. If you are not the member, please clarify your relationship to the member and provide any necessary documentation.
10. Once you have completed all sections, you can save the form, download it, print it, or share it as needed.

Complete your documents online today to ensure your information is processed efficiently.