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
