Medical Release:

The Trinity Rose Foundation agrees that all medical information will remain confidential and any reports written about the program will not use any participants’ names without their express permission. I specifically authorize the release of my healthcare and billing information in your organization’s possession. The purpose of my request is to assist the Trinity Rose Foundation in determining my eligibility for financial assistance. The Trinity Rose Foundation will not disseminate or release these medical records to any outside source without first obtaining my prior expressed consent. I understand and agree that fulfillment of assistance may result in publicity whether or not the Trinity Rose Foundation actively takes steps to publicize its service. I understand and recognize that the granting of any service and the participation of any person in the assistance is contingent upon approval by the Trinity Rose Foundation. I also understand that there is a limit to the number of services that I will receive, depending on the type and cost of service being requested and offered. I understand and agree that no promises or assurances whatsoever have been made to me by any representatives of the Trinity Rose Foundation regarding the assistance I am requesting.

We also ask that you upload one of the following via the upload link below:

a pathology/evaluation report clearly showing patient name, doctor/therapist name, diagnosis and identifies the hospital, or
an IEP report showing your child's name, school system, and assessment

Finally, please acknowledge this medical release by e-signing below:

I understand and grant my permission to all my doctors, social workers, clinics and hospitals to release all healthcare and billing information relating to my eye condition and care and other related health problems to the Trinity Rose Foundation. I also grant my permission to discuss the above information with any designated representative of the Trinity Rose Foundation by phone.