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THRIVING KIDS PROJECT

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GUIDANCE CENTER

Clinical Services & Programs

Disclosure Of Information: General

FOR BERNALILLO, SANDOVAL & VALENCIA COUNTY ONLY. Intake forms are securely encrypted and HIPAA compliant.

Disclosure Of Health Information

ID #
CLIENT FIRST NAME*
CLIENT LAST NAME*
CLIENT DOB*
MM slash DD slash YYYY
CLIENT EMAIL*
I hereby authorize Southwest Family Guidance Center & Institute to receive information from and disclose information to:
RECIPIENT NAME*
OR APPROPRIATE STAFF AT THEIR ORGANIZATION:*
RECIPIENT PHONE*
RECIPIENT ADDRESS*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
RECIPIENT EMAIL*
RECIPIENT FAX*
FOR THE PURPOSE OF:*
INFORMATION TO BE DISCLOSED (Does not include psychotherapy notes)*
- TREATMENT SUMMARY
- TREATMENT PLAN
- INITIAL ASSESSMENT
- CLINICAL ASSESSMENT
- DISCHARGE DOCUMENTATION
- BILLING STATEMENT
- OTHER
PLEASE SPECIFY:
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
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 CLIENT 14 YEARS OF AGE OR OLDER?*
- YES
- NO
NAME OF PARENT, SIGNATURE OF PARENT, GUARDIAN, OR LEGAL REPRESENTATIVE*
RELATION TO CLIENT*
DATE*
MM slash DD slash YYYY

SECURING FORM

PRIMARY PHONE LINE
(505) 830-1871

PRIMARY FAX LINE
(505) 830-0040

Albuquerque Main Office

2221 Rio Grande Blvd NW
Albuquerque, NM 87104
(505) 830-1871

Albuquerque East Office

2612 Texas St. NE
Albuquerque, NM 87110
(505) 830-1871

Las Cruces: Telshor Office

755 S. Telshor Blvd, Suite 201B
Las Cruces, NM 88011
(575) 524-6820

Las Cruces: Don Roser Office

1401 Don Roser, Suite F1-F2
Las Cruces, NM 88011
(575) 524-6820

Santa Fe Office

4001 Office Court Dr. Suite 603
Santa Fe, NM 87507
(505) 310-4764

© SOUTHWEST FAMILY GUIDANCE CENTER & INSTITUTE | ALL RIGHTS RESERVED | WEBSITE BY MERIDIANSIX SANTA FE-ALBUQUERQUE | LEGAL

© SOUTHWEST FAMILY GUIDANCE CENTER & INSTITUTE

ALL RIGHTS RESERVED | LEGAL | WEBSITE BY MERIDIANSIX

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