Release of Information Forms

408 S. PARK AVE.
AZTEC, NM 87410

505.334.1994 (p)

505.334.1999 (f)

contact@cheartsllc.com

C O M P A S S I O N A T E H E A R T S, L L C

MEDICAL CANNABIS CARD ASSISTANCE & CBD STORE

DOWNLOADABLE FORMS

FIND YOUR FORM

We have three different release of information forms available for download below. Most medical offices will accept the Compassionate Hearts release form, however, San Juan Health Partners and the Department of Veteran Affairs require their own release form be filled out. Please select the appropriate form, download it, fill it out, sign it and send it back. You can fax it to us at 505.334.1999 or email it to us at contact@cheartsllc.com

COMPASSIONATE HEARTS

RELEASE OF INFORMATION FORM

Click on the above image to download this form. This form is accepted by most medical offices. If your provider is affiliated with San Juan Health Partners, please select the release form for San Juan Health Partners. If your provider is affiliated with the VA, please select the release form for the VA.

SAN JUAN HEALTH PARTNERS

RELEASE OF INFORMATION FORM

Click on the above image to download this form. This form is used by all providers affiliated with San Juan Health Partners and is the only release form they will accept. A clear copy of the patient's ID is required as well.

DEPARTMENT OF VETERAN AFFAIRS

RELEASE OF INFORMATION FORM

Click on the above image to download this form. This only release form they will accept. Please make sure the patient fills out both pages.

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We care about our clients and want the process of enrollment into the

New Mexico Medical Cannabis Program to be as easy as possible.

New patients are required to have current medical records that support the qualifying condition the patient is applying under. We can assist with obtaining the necessary medical records by having the client fill out a Release of Information Form.