Disclosure Of Information: Primary Care Physician, Santa Fe, Rio Arriba FOR SANTA FE & RIO ARRIBA COUNTIES ONLY. Intake forms are securely encrypted and HIPAA compliant. Disclosure Of Information: Primary Care Physician ID # CLIENT FIRST NAME*CLIENT LAST NAME*CLIENT DOB* MM slash DD slash YYYY CLIENT EMAIL* DOES THE CLIENT HAVE A PRIMARY CARE PHYSICIAN (PCP)?* YES NO BY SIGNING BELOW I VERIFY THAT THERE IS NO PRIMARY CARE PHYSICIAN WHO CAN COLLABORATE WITH SOUTHWEST FAMILY GUIDANCE CENTER.PCP NAME*PCP PHONE*PCP ADDRESS* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PCP EMAIL (IF KNOWN) PCP FAX (IF KNOWN)MAY WE COLLABORATE WITH YOUR PRIMARY CARE PHYSICIAN?* YES NO COVERING THE PERIOD FROM:* MM slash DD slash YYYY COVERING THE PERIOD TO:* UNTIL DISCHARGE FROM SWFGC UNTIL SPECIFIC DATE SPECIFY END DATE:* MM slash DD slash YYYY BY SIGNING BELOW I VERIFY THAT I DO NOT AUTHORIZE CARE COLLABORATION WITH MY PRIMARY CARE PHYSICIAN.I AUTHORIZE SOUTHWEST FAMILY GUIDANCE CENTER TO NOTIFY MY PRIMARY CARE PHYSICIAN THAT I HAVE STARTED SERVICES.* YES NO I AUTHORIZE SOUTHWEST FAMILY GUIDANCE CENTER TO NOTIFY MY PRIMARY CARE PHYSICIAN WHEN I HAVE DISCHARGED FROM SERVICES.* YES NO I AUTHORIZE SOUTHWEST FAMILY GUIDANCE CENTER TO RECEIVE RECENT AND RELEVANT MEDICAL RECORDS FROM MY PRIMARY CARE PHYSICIAN.* YES NO I UNDERSTAND THAT I HAVE A RIGHT TO REVOKE THIS AUTHORIZATION AT ANY TIME.* YES NO I UNDERSTAND THAT IF I REVOKE THIS AUTHORIZATION I MUST DO SO IN WRITING AND PRESENT MY WRITTEN REVOCATION TO THE AGENCY PRIVACY OFFICER.* YES NO I UNDERSTAND THAT THE REVOCATION WILL NOT APPLY TO INFORMATION THAT HAS ALREADY BEEN RELEASED IN RESPONSE TO THIS AUTHORIZATION.* YES NO I UNDERSTAND THAT THE REVOCATION WILL NOT APPLY TO MY INSURANCE COMPANY WHEN THE LAW PROVIDES MY INSURER WITH THE RIGHT TO CONTEST A CLAIM UNDER MY POLICY.* YES NO I UNDERSTAND THAT UNLESS OTHERWISE REVOKED, THIS AUTHORIZATION WILL REMAIN IN EFFECT UNTIL DATES SPECIFIED. IF NO EXPIRATION DATE OR EVENT IS OTHERWISE LISTED HERE, I UNDERSTAND THAT THIS AUTHORIZATION WILL EXPIRE ONE YEAR AFTER THE DATE IT IS SIGNED.* YES NO I UNDERSTAND THAT UNDER NMSA 1978 § 32A-6A-24, A CHILD HAS A RIGHT TO EXAMINE AND COPY CONFIDENTIAL INFORMATION ABOUT THE CHILD THAT IS TO BE DISCLOSED, THE NAME OR TITLE OF THE PROPOSED RECIPIENT OF THE INFORMATION, AND A DESCRIPTION OF THE USE THAT MAY BE MADE OF THE INFORMATION.* YES NO I UNDERSTAND THAT ONCE THE ABOVE INFORMATION IS DISCLOSED, IT MAY BE RE-DISCLOSED BY THE RECIPIENT AND THE INFORMATION MAY NOT BE PROTECTED BY FEDERAL PRIVACY LAWS OR REGULATIONS.* YES NO I UNDERSTAND THAT AUTHORIZING THE DISCLOSURE OF THIS HEALTH INFORMATION IS VOLUNTARY. I NEED NOT SIGN THIS FORM IN ORDER TO OBTAIN HEALTH CARE TREATMENT.* YES NO IF THE CLIENT IS 14 YEARS OF AGE OR OLDER, THEY MUST SIGN THIS DOCUMENT THEMSELVES. IF THE CLIENT IS UNDER 14 YEARS OF AGE, THE DOCUMENT MUST BE SIGNED BY PARENT, GUARDIAN, OR LEGAL REPRESENTATIVE. IS THE CLIENT 14 YEARS OF AGE OR OLDER?* YES NO NAME OF PERSON COMPLETING THIS FORM*RELATION TO CLIENT*DATE* MM slash DD slash YYYY
