I hereby authorize Trivium New England Integrative Mental Health to share and/or obtain my health information, in verbal, written and/or any other form as required for the purpose of the disclosure as described below, to/from:
name(s) facility street address city state zip phone number fax number
My health information to be shared includes (select one): All health information pertaining to my medical history, including mental health treatment records Only the following mental health treatment records or types of health information (including any dates): I specifically authorize the release of drug and alcohol abuse treatment records: (initial if applicable) Purpose of disclosure: Treatment Planning/Coordination of Care Other: (specify) (expiration event/date )