Trillium Consent for Release of Member InformationManuals, Forms and Resources - TrilliumProvider Do 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the enrollee’s full name, any previous names, date of birth, and social security number if available.
3. If the member is present, have them print their name in the statement: 'I, _____ hereby request and authorize…'. If you are the provider requesting records, include your practice name and your own name.
4. Specify the organization or facility from which the records will be obtained. Examples include Southeastern Center or Roanoke/Chowan Human Services Center.
5. Indicate where you want the records sent by providing a full address and fax number.
6. Clearly state which specific records you wish to receive, such as medication lists or psychological evaluations.
7. Define the purpose for this disclosure (e.g., Care and Treatment).
8. Set an expiration date for this authorization, typically one year from signing.
9. Sign and date the form. If you're not the member, indicate your relationship and provide necessary documentation.

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