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 CLINICIANPOWER OF ATTOURNEYEXECUTORCLIENT FIRST NAME*CLIENT LAST NAME*CLIENT DOB Date Format: MM slash DD slash YYYY WHAT TYPE OF INFORMATION IS BEING REQUESTED?*A SUMMARY OF RECORDS MAINTAINEDCOPIES OF SPECIFIC RECORDSDATE FROM:* Date Format: MM slash DD slash YYYY DATE TO:* Date Format: 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?*MAILIN-PERSONEMAILNAME 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 87104Los Lunas Office: 719 Los Lentes Rd. NE, Los Lunas, NM 87031Santa Fe Office: 4001 Office Court Dr. Suite 603, Santa Fe, NM 87507Las Cruces Office: 755 S. Telshor Blvd, Suite 201B, Las Cruces, NM 88011NAME OF RECIPIENT*RECIPIENT EMAIL UPLOAD A PHOTO OF IDENTIFICATION OR OTHER FORM OF AUTHORIZATON
