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Trinity Health Release

Authorization For Use or Disclose of Medical Record Information 

Return Completed Forms to:

Please return to your Local Practice

Patient Information

I hereby Authorize Trinity Health Of New England Medical Group:

Please choose one:

Specific Records to be released:

Charges for medical copies are governed by both state and federal regulations. Delivery costs are also charged.

STOP: IMPORTANT - It is extremely important that you select either YES or NO and Initial each item contained in this section Authorization to Release Protected Information. Please do not skip any line item as it could impact our ability to fulfill your request and cause additional delays.

> HIV Testing
> Allied Mental Health and Human Services Professional communications
> Genetic Testing
> Psychologist and Social Worker communications
> Substance Abuse
> Sexually Transmitted Diseases

Term: This Authorization will remain in effect until Trinity Health Of New England Medical Group fulfills this request. Revocation: I understand that I may revoke this Authorization at any time by requesting it of Trinity Health Of New England Medical Group in writing at the address listed below. The revocation will be effective immediately upon Trinity Health Of New England Medical Group receipt of my written notice. I understand that the revocation will not have any effect on any action taken by Trinity Health Of New England Medical Group in reliance on this Authorization before it received my written notice of revocation.

Effect on Treatment: I understand that I may refuse to sign this Authorization for any reason and that such refusal will not affect the commencement, continuation, quality or payment for such treatment at Trinity Health Of New England Medical Group.

Potential for Redisclosure: I understand the person receiving my Protected Health Information may not be required to comply with federal & state Privacy laws & my Protected Health Information may no longer be protected by the applicable state & federal law once it is disclosed by Trinity Health Of New England Medical Group

Thank you for taking the time to fill out this form.

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Office Hours

Monday:

8:00 am-12:00 pm

1:00 pm-6:00 pm

Tuesday:

8:00 am-12:00 pm

1:00 pm-6:00 pm

Wednesday:

8:00 am-12:00 pm

1:00 pm-6:00 pm

Thursday:

8:00 am-11:00 am

11:30 am-1:00 pm

Friday:

Closed

Saturday:

Closed

Sunday:

Closed

Office Hours

Our Regular Schedule

Monday:

8:00 am-12:00 pm

1:00 pm-6:00 pm

Tuesday:

8:00 am-12:00 pm

1:00 pm-6:00 pm

Wednesday:

8:00 am-12:00 pm

1:00 pm-6:00 pm

Thursday:

8:00 am-11:00 am

11:30 am-1:00 pm

Friday:

Closed

Saturday:

Closed

Sunday:

Closed