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CHILDREN, YOUTH AND FAMILIES DEPARTMENT (NM Children, Youth & Families Department - CYFD)

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STATE OF NEW MEXICO
CHILDREN, YOUTH AND FAMILIES DEPARTMENT
CHILD PROTECTIVE SERVICES DIVISION
STATEWIDE CENTRAL INTAKE
RE
QUEST FOR DISCLOSURE OF CONFIDENTIAL INFORMATION
Date of Request: __________________________
Case Name: ______________________________
Names and Dates of Birth of Individuals: ________________________________________
________________________________________
________________________________________
________________________________________
________________________________________
I certify that I am one of the following persons entitled to receive information from the New Mexico
Children, Youth and Families Department concerning this case/individuals:
_____
Other State social services agency
Description of record disclosure requested:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
FACTS case # (if known): ____________________
Name, address, email and telephone number of person or entity requesting disclosure (Requester):
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
I, the undersigned Requester, certify that I am familiar with the statute governing confidentiality of all
records concerning protective services records and state that I am an individual identified above who is
entitled to receive the information and/or records requested. Upon receipt of the information and/or
records provided by the New Mexico Children, Youth and Families Department, I hereby AGREE not to re
-disclose the information described herein to any other person or organization except as otherwise
provided by law
.
________
_______________ __________________________________
Date Requester’s signature
________
__________________________
Title/Position
Please return completed form to:
New Mexico Children, Youth and Families Department
Protective Services Division
Statewide Central Intake
Email: SCI.LEReports@state.nm.us
Subject: REQUEST FOR DISCLOSURE OF CONFIDENTIAL INFORMATION
The informa
tion described herein is confidential and/or privileged pursuant to NMSA 1978 §32A-4-33.
Disclosure or redistribution is prohibited and is a petty misdemeanor that may result in incarceration of
not more than six (6) months, a fine of not more than five hundred dollars ($500.00), or both.
Below
information is to be filled out by New Mexico Children, Youth and Families Department
employee who completed the disclosure.
______________________________________ ________________________
Signature of CYFD employee making disclosure Date and time disclosure made
______________________
________________
Printed name of CYFD employee making disclosure
______________________
________________
Title/Position of CYFD employee making disclosure
If the New
Mexico Children, Youth and Families Department employee is unable to contact the
requestor and make disclosure:
________________________
Date and time attempt was made
__________________________________________
Signature of CYFD employee making attempt 1
__________________________________________
Printed name of CYFD employee making attempt 1
__________________________________________
Title/Position of CYFD employee making attempt 1
__________________________________________
Signature of CYFD employee making attempt 2
__________________________________________
Printed name of CYFD employee making attempt 2
__________________________________________
Title/Position of CYFD employee making attempt 2
__________________________________________
Signature of CYFD employee making attempt 3
__________________________________________
Printed name of CYFD employee making attempt 3
__________________________________________
Title/Position of CYFD employee making attempt 3
________________________
Date and time attempt was made
________________________
Date and time attempt was made
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CHILDREN, YOUTH AND FAMILIES DEPARTMENT (NM Children, Youth & Families Department - CYFD)

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Completed 4 March 2021

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