Forms

NMSIIS User Security and Confidentiality Agreement 2024

Participant organization security and confidentiality agreement for the New Mexico Statewide Immunization Information System.

This form may be used by individuals requesting a religious or medical exemption to immunization for their children whom attend any public, private or parochial pre-school, kindergarten, elementary, secondary school, or home school and for children attending daycare of childcare facilities.

Certificate of Exemption FAQ

This form may be used by individuals requesting a religious or medical exemption to immunization for their children whom attend any public, private or parochial pre-school, kindergarten, elementary, secondary school, or home school and for children attending daycare of childcare facilities.

This form is to be used by agencies and organizations to document eligibility. This should not be accepted in place of a birth certificate.

This authorization allows the Department of Health (DOH) to disclose confidential health information about you. The authorization may be revoked. It will remain in effect for six (6) months unless a different time is stated. You are entitled to a copy of the completed authorization. There may be fees charged for any copying associated with this request. If you are a person with a disability and you require this authorization in an alternative format or require a special accommodation to complete this form, you may request assistance from staff at any DOH location or from the DOH Chief Privacy Officer.

Authorization to Disclose Health Information (Spanish)

This form is used by a patient/parent/legal guardian to remove records from the New Mexico Statewide Immunization Information System.

NMSIIS Decision to Remove Record (Spanish)

This form is used by a patient/parent/legal guardian to decline to participate in the New Mexico Statewide Immunization Information System.

NMSIIS Decline to Participate (Spanish)

Client Rights Grievance Process and ANE Reporting Form

Use this form to order sample collection kits.

Case Management - General and Individual Specific Interview Survey Tool

Mi Via Administrative Requirements and Interview

Case Management - Administrator Interview Tool

Case Management - Billing Tool

Case Management - Individual Record Review Survey Tool

Case Management - Surveyor Instructions

Mi Via Requirements for Consultants

Mi Via Consultant Job Knowledge Interview Survey Tool

Mi Via Consultant: Participant Specific Interview Survey Tool

Mi Via Billing Tool