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New Mexico Authorization Form

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NEW MEXICO WORKERS’ COMPENSATION ADMINISTRATION
WORKER’S AUTHORIZATION FOR USE AND DISCLOSURE OF HEALTH RECORDS

Worker/Patient FULL NAME:   DOB:   SSN:

FOR WCA REFERENCE ONLY:  Date/s of Injury:   WCA Case File Number:

INSTRUCTIONS FOR USE:

In accordance with Section 52-10-1 NMSA 1978, a workers’ compensation health care provider shall not require a signed medical authorization, in any form, for records that are directly related to any work place injuries or disabilities claimed by an injured worker. Costs for copying records are subject to non-clinical services fees set by the Administration, and shall not exceed $1.00 per page for the first ten (10) pages or up to twenty-cents ($0.20) for each page thereafter. A copy of this authorization may be used as an original.

Este formulario es obligatorio al presentar una queja. Si necesitas ayuda para completar este formulario, póngase en contacto con un ombudsman (866) 967-5667.

RELEASE OF HEALTH CARE RECORDS

I, (Worker’s Name) , hereby authorize the following health care provider (HCP) or named facility to release my health care records for the PURPOSE OF facilitating and evaluating my Worker’s Compensation Claim that arises from alleged workplace injuries or illnesses that occurred on the above date/s of injury.

Provider or Facility:

Address:

Telephone No.:

I authorize the following records released (check box, as appropriate):

provide a date range for records authorized to be released

RELEASE OF SPECIFIC HEALTH RECORDS

I FURTHER AUTHORIZE THE RELEASE OF RECORDS THAT MAY CONTAIN INFORMATION ABOUT THE FOLLOWING: (check any that may apply).

Signature of Worker/Patient/Personal Representative

Date

PERSON/ENTITY AUTHORIZED TO RECEIVE RECORDS

I authorize records be released to my employer, my employer’s insurer, my attorney or representative, my employer/insurer’s attorney or representative, and IME providers.

(To be completed by authorized recipient/s): Records to be (specify):

Authorized Recipient/s:

Address:

Telephone No.:

Fax/Email:

EXPIRATION

I UNDERSTAND THAT THIS AUTHORIZATION IS VOLUNTARY AND THAT I MAY REFUSE TO SIGN IT AND SUCH A REFUSAL TO SIGN MAY NOT AFFECT MY TREATMENT OR SERVICES, EXCEPT AS PERMITTED BY LAW. THIS AUTHORIZATION IS LIMITED TO USE AND DISCLOSURE OF MEDICAL RECORDS AND DOES NOT WAIVE ANY PATIENT DOCTOR PRIVILEGE WITHOUT MY SEPARATE AUTHORIZATION AND CONSENT. THIS AUTHORIZATION IS TO BE VALID FOR TWO (2) YEARS FROM THE DATE OF MY SIGNATURE. I UNDERSTAND THAT INFORMATION DISCLOSED PURSUANT TO THIS AUTHORIZATION MAY BE REDISCLOSED BY THE RECIPIENT/S. I MAY REVOKE THIS AUTHORIZATION AT ANY TIME BY NOTIFYING THE HEALTH CARE PROVIDER OR FACILITY IN WRITING; A COPY OF ANY REVOCATION SHOULD BE PROVIDED TO THE RECIPIENT/S. UPON MY REQUEST, I AM ENTITLED TO A COPY OF THE SIGNED AUTHORIZATION.

Signature of Worker/Patient

Date

Signature of Personal Representative (if any)

Date

Printed Name of Personal Representative

Relationship to Worker/Patient

Rev. 10/17

11.4.4.9 NMAC

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What the New Mexico Authorization Form Is and when it’s used

The New Mexico Authorization Form is a written record used to grant another person or organization the legal authority to act, access records, or receive information on behalf of the signer. Common uses include medical records release, financial authorization, third‑party representation, and agency consent. The form documents who is authorized, what actions are permitted, effective dates, and any limitations. Electronic completion and e‑signatures are generally acceptable under the federal ESIGN Act (15 U.S.C. ch. 96) and the Uniform Electronic Transactions Act (UETA), which New Mexico has adopted for intrastate transactions.

Why a clear authorization form matters

A properly completed authorization reduces disputes, documents consent, and creates an auditable record of permissions. It protects both the principal and recipient by defining scope, duration, and revocation procedures, and supports compliance with ESIGN (15 U.S.C. §7001) and applicable state rules.

Why a clear authorization form matters

Who commonly completes or receives this form

Several roles routinely complete or request a New Mexico Authorization Form depending on the context.

  • Healthcare providers and release coordinators requesting patient records for continuity of care or third‑party billing.
  • Financial institutions and payors authorizing account access, tax matters, or benefit distributions.
  • Attorneys and legal representatives obtaining client permission to represent, access files, or receive confidential materials.

Each profile has distinct requirements; choose language and supporting documents that match the intended use.

Typical signer profiles and use cases

Clinic Administrator

A clinic administrator completes medical release authorizations to share records with specialists or insurers. They ensure HIPAA language and effective dates are present and request patient identity proofs when required.

Property Manager

A property manager uses authorization forms to permit third parties to submit maintenance requests, collect rent, or access tenant records. The form must specify scope, duration, and whether financial transactions are allowed.

Stepwise completion process

Complete the form in this order to reduce errors and speed acceptance by recipients.

  • 01
    Prepare: Gather IDs, account numbers, and relevant contact details.
  • 02
    Specify Scope: Write a clear description of what is authorized and any limits.
  • 03
    Sign and Date: Sign in ink or e‑sign with authentication and add the date.
  • 04
    Deliver and Retain: Send to the recipient and keep a signed copy for records.

Typical digital signing and submission flow

Digital workflows speed completion while preserving an audit trail when configured correctly.

  • Upload Document: Start by uploading the blank authorization form to your signing platform.
  • Place Fields: Add signature, date, and identity fields where required on the form.
  • Authenticate Signer: Use email, SMS, or stronger authentication based on sensitivity.
  • Deliver Signed Copy: Send executed copy to all parties and store the audit trail.

Recommended online workflow settings

Configure these settings when you build a reusable online authorization template.

Field Configuration
Authentication Level Email or SMS code for standard forms; KBA for higher risk.
Template Locks Lock non‑fillable text to prevent scope changes.
Remote Notarization Enable RON if notarization is required and state law permits.
Retention Policy Automatically archive signed copies with audit data for required retention.

Technical needs for e‑submission and integrations

Choose platform features that match your security and integration requirements.

  • File formats: PDF, DOCX, and HTML supported
  • Integrations: Salesforce, NetSuite, Google Workspace
  • Authentication: Email, SMS, KBA, SSO

Timing considerations and common deadlines

Understand time‑sensitive elements so that permissions start and stop as intended.

When to provide:

Give the completed form to the requester upon their request or before the service date.

Effective date:

Authorizations become valid on the effective date entered by the signer.

Expiration date:

Set explicit expiration to prevent indefinite access.

Revocation notice:

Allow 7–14 days for the recipient to process revocation; document delivery method.

Notary scheduling:

If notarization is required, schedule within a few days to avoid delay.

Common errors that delay acceptance

  • Incomplete recipient details or vague purpose descriptions that leave authority ambiguous and trigger rejection.
  • Mismatched signer name or signature that fails identity checks and prevents third‑party acceptance.
  • Missing dates, unsigned pages, or initials where required, which invalidate the form for administrative use.
  • Using generic or overly broad language that allows unintended disclosures or exceeds the principal’s intent.

Risks and potential consequences of a flawed authorization

Unauthorized Disclosure: Privacy breaches and potential regulatory enforcement
HIPAA Liability: Civil penalties for improper PHI release
Contract Invalidity: Recipient may refuse action without valid authorization
Financial Exposure: Unauthorized financial transfers risk loss
Operational Delay: Processing and service delays for corrections
Legal Dispute: Potential litigation over scope or revocation

eSignature vendor pricing and capability snapshot

Compare basic price and common capabilities across representative vendors; signNow appears first as the first column per page conventions.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Yes, trial available Yes, trial available Yes, trial available Yes, trial available
Bulk Send Yes (Premium) Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Best practices for accurate, enforceable authorizations

Follow these practical steps to improve acceptance and reduce downstream risk.

Use precise language
Define the recipient, purpose, and time limits clearly to avoid ambiguity.
Verify identity
Require government ID or multi‑factor authentication for sensitive authorizations.
Record retention
Keep signed originals and an electronic audit trail for the required statutory period.
Specify revocation
Include clear revocation procedure and delivery method to terminate permissions reliably.

FAQs and troubleshooting for New Mexico Authorization Forms

Answers to frequent questions about enforceability, notarization, revocation, and supporting documentation.


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