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Disclosure Of Information: Primary Care Physician

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

  • Disclosure Of Information: Primary Care Physician
    ID #
  • MM slash DD slash YYYY
  • BY SIGNING BELOW I VERIFY THAT THERE IS NO PRIMARY CARE PHYSICIAN WHO CAN COLLABORATE WITH SOUTHWEST FAMILY GUIDANCE CENTER.

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • BY SIGNING BELOW I VERIFY THAT I DO NOT AUTHORIZE CARE COLLABORATION WITH MY PRIMARY CARE PHYSICIAN.

  •  

    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.


  • MM slash DD slash YYYY
Serving New Mexico
families for over 20 years.
Albuquerque Main Office

2221 Rio Grande Blvd NW
Albuquerque, NM 87104
(505) 830 1871
(505) 830 0040 Fax

Las Cruces: Telshor Office

755 S. Telshor Blvd, Suite 201B
Las Cruces, NM 88011
(575) 524 6820
(575) 526 9304 Fax

Santa Fe Office

4001 Office Court Dr. Suite 603
Santa Fe, NM 87507
(505) 310 4764
(505) 830 0040 Fax

Albuquerque East Office

2612 Texas St. NE
Albuquerque, NM 87110
(505) 830 1871
(505) 830 0040 Fax

Las Cruces: Don Roser Office

1401 Don Roser, Suite F1-F2
Las Cruces, NM 88011
(575) 524 6820
(575) 526 9304 Fax

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