Disclosure Of Information: APS Disclosure Of Health Information ID # STUDENT FIRST NAME*STUDENT LAST NAME*STUDENT DOB* MM slash DD slash YYYY STUDENT OR PARENT EMAIL* I hereby authorize Southwest Family Guidance Center & Institute to receive information from and disclose information to Albuquerque Public Schools for the purpose of collaborative care.NAME OF APS CONTACT*APS CONTACT PHONE*APS CONTACT EMAIL* NAME OF SCHOOL*SCHOOL ADDRESS* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code SCHOOL FAX*INFORMATION TO BE DISCLOSED (Only the following three items may be disclosed. Check all that apply.)* INFORM SCHOOL THAT STUDENT ATTENDED ASSESSMENT INFORM SCHOOL OF STUDENT'S RISK LEVEL INFORM SCHOOL OF CLINICAL RECOMMENDATIONS I DO NOT AUTHORIZE THE RELEASE OF ANY INFORMATION COVERING THE PERIOD FROM TODAY UNTIL:* END OF CURRENT SCHOOL YEAR UNTIL SPECIFIC DATE SPECIFY END DATE: MM slash DD slash YYYY I AUTHORIZE THE RELEASE OF THE FOLLOWING INFORMATION* Select All ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) OR HUMAN IMMUNODEFICIENCY VIRUS (HIV) INFECTION OR OTHER SEXUALLY TRANSMITTED DISEASES BEHAVIORAL HEALTH SERVICES/PSYCHIATRIC CARE TREATMENT FOR ALCOHOL AND/OR DRUG ABUSE 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 IS THE STUDENT 14 YEARS OF AGE OR OLDER?* YES NO NAME OF PARENT, SIGNATURE OF PARENT, GUARDIAN, OR LEGAL REPRESENTATIVE*RELATIONSHIP TO STUDENT*DATE* MM slash DD slash YYYY
