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        • Is TMS Treatment Right for Me? Take the Quiz.
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Home » For Patients » Medical Records Requests

Release of Medical Records

  • Release of Medical Records

    If requesting records for a minor, please note that under HIPAA (45 CFR § 164.502(g))., a parent/guardian generally has access to their child’s medical records. However, an exception is made if the minor consents to care that does not require parental/guardian consent under state law. Most providers take the position that if the minor can consent for the service, then they have the right to confidentiality and control access to and disclosure of medical records for those services. Read more on the New Mexico Department of Health’s website.

    Please Complete Form Completely

    I hereby request and authorize the release of medical, mental health, & substance abuse records of:

  • This form allows Sage Neuroscience Center to: Release and/or obtain copies of patient’s medical chart

    Please check all that apply.

  • All Releases Expire After One Year

    By signing this, I am in agreement to the release of information between Sage Neuroscience Center and its providers and the above listed individual/health care providers. I am aware that this release is strictly limited to the contents of my records as checked above. I understand that information regarding active suicidal and homicidal ideation or other known or suspected harm to self or others is not protected under the Health Information Privacy and Portability Act (HIPAA). Disclosing such information is at the discretion of Sage Neuroscience Center to release and would be done so strictly to ensure safety and security. I do not have to sign this authorization in order to receive treatment from Sage Neuroscience Center. I have the right to refuse to sign this authorization. When my information is used or disclosed pursuant to this authorization, it may be subject to redisclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule. I agree not to hold Sage Neuroscience Center liable for such third-party disclosure. I have the right to revoke this authorization in writing (except to the extent that Sage Neuroscience Center has already acted in response to this authorization), which must be submitted to the Office Manager at the above address. PROHIBITION OF REDISCLOSURE: Federal regulations (42 CFR Part 2) and State Laws (NMSA 1978 43-1-19, 32A-6A-24, 24-2B-7, and 24- 1-9.5) prohibit further disclosure of mental health or alcohol and/or drug abuse treatment information, and the results of tests for HIV/AIDS and other sexually transmitted diseases to any person or agency without securing another proper written authorization for that purpose, or otherwise permitted by Federal regulations or State laws.
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For more information about our services, contact us today at

1 (505) 884-1114

Our mission is to provide comprehensive behavioral health and substance use treatment to the community.  We empower individuals to achieve health, wellness and recovery.

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    All Services: 1 (505) 884-1114

    Fax: 505-884-3004

    7850 Jefferson St. NE, Suite 300
    Albuquerque, NM 87109

    Monday - Friday: 8:00am - 5:00pm

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