Request For Access To Protected Health Information (PHI) Please allow up to 2–4 weeks from initial date of request to receive client records. General Intake Form ID # REQUESTER FIRST NAME*REQUESTER LAST NAME*REQUESTER ADDRESS* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code REQUESTER PHONE*REQUESTER EMAIL* SELECT THE OPTION THAT BEST DESCRIBES THE ROLE OF THE REQUESTER* SWFGC CLINICIAN POWER OF ATTOURNEY EXECUTOR CLIENT FIRST NAME*CLIENT LAST NAME*CLIENT DOB MM slash DD slash YYYY WHAT TYPE OF INFORMATION IS BEING REQUESTED?* A SUMMARY OF RECORDS MAINTAINED COPIES OF SPECIFIC RECORDS DATE FROM: MM slash DD slash YYYY DATE TO: MM slash DD slash YYYY SPECIFY RECORDS INITIAL ASSESSMENT OTHER ASSESSMENTS BILLING STATEMENT DISCHARGE PLAN SERVICES RECEIVED AT SWFGC OTHER PLEASE SPECIFY:*HOW WOULD YOU LIKE TO RECEIVE THE RECORDS?* MAIL IN-PERSON EMAIL NAME OF RECIPIENT*RECIPIENT ADDRESS* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code I WOULD LIKE TO PICK UP RECORDS AT THE FOLLOWING LOCATION:* Albuquerque Main Office: 2221 Rio Grande Blvd NW, Albuquerque, NM 87104 Los Lunas Office: 719 Los Lentes Rd. NE, Los Lunas, NM 87031 Santa Fe Office: 4001 Office Court Dr. Suite 603, Santa Fe, NM 87507 Las Cruces Office: 755 S. Telshor Blvd, Suite 201B, Las Cruces, NM 88011 NAME OF RECIPIENT*RECIPIENT EMAIL* UPLOAD A PHOTO OF IDENTIFICATION OR OTHER FORM OF AUTHORIZATONAccepted file types: jpg, jpeg, png, gif.
