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New Mexico · Attorney-Style Template

New Mexico HIPAA Authorization Form

Fill-in-the-Blank · State-Specific · Instant Download

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What's Included

Fill-in-the-blank New Mexico HIPAA Authorization for Release of Protected Health Information. Compliant with N.M. Stat. Ann. §§ 24-10B-1 et seq. (New Mexico Mental Health and Developmental Disabilities Code) and 45 C.F.R. § 164.508. Covers authorized person identification, scope of PHI release (including behavioral health and substance use per New Mexico law), purpose of disclosure, expiration, revocation rights, and notary acknowledgment block compliant with N.M. Stat. Ann. § 14-12A-1. Suitable for estate administration, healthcare proxy coordination, and insurance purposes. Instant .docx download.

Patient identification and authorization block
Authorized recipient designation
Covered healthcare provider(s) to release records
Granular description of records to release (checkboxes)
Psychiatric, substance abuse, HIV/AIDS, genetic record options
Purpose of disclosure (treatment, legal, estate, insurance)
Expiration date or event selection
Patient rights notices (revocation, voluntary, re-disclosure)
State-specific statutory compliance language
Personal Representative authority block
Witness attestation
Optional notary acknowledgment
HIPAA 45 C.F.R. §164.508 compliant

Who This Is For

  • Residents with straightforward estates
  • Individuals who want a solid will without attorney fees
  • Married couples (each spouse needs their own)
  • Anyone ready to get their affairs in order

NOT Appropriate For

  • Business owners with complex ownership interests
  • Blended families with competing inheritance claims
  • Property owners in multiple states
  • Taxable estates (over federal exemption)

Legal Disclaimer

This template is for informational purposes only and does not constitute legal advice. No attorney-client relationship is formed by purchase. Consult a licensed New Mexico attorney for advice specific to your situation.

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