New Mexico Department of Health
Our mission is to promote health and wellness, improve health outcomes, and assure safety net services for all people in New Mexico.
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Forms



Photo of the publication cover. Mi Via Self-Directed Waiver: Service and Support Back-Up Plan Acknowledgement Form Mi Via Self-Directed Waiver - Form April 18, 2018

Mi Via Self-Directed Waiver: Service and Support Back-Up Plan Acknowledgement Form



Photo of the publication cover. Medical Cannabis License ID Card Request Medical Cannabis Program - Form April 9, 2018

This form should be used to request a card for all new Licensed Nonprofit Producer employees, Board Members, or contract worker or to request a replacement card for one of these staff members. For a new employee card please ensure you submit the items requested on the form.



Photo of the publication cover. CMS Telephone Referral Form Children's Medical Services - Form April 5, 2018

CMS Telephone Referral Form



Photo of the publication cover. New Mexico J-1 Waiver Application 2019 Primary Care & Rural Health - Form March 28, 2018

The New Mexico J-1 waiver program allows foreign medical graduates to obtain a waiver of their 2 year foreign residence requirement in exchange for a commitment to practice in underserved areas of New Mexico after the completion of their training.

Attachment A
Attachment C



Photo of the publication cover. VFC New Provider Application Immunization - Form March 23, 2018

All VFC providers are required to submit this annual VFC certification form in order to continue receiving VFC vaccines.

VFC Instructions on Digital Signature and Attaching License



Photo of the publication cover. Occupational Health Case Reporting Occupational Health Surveillance - Form March 15, 2018

This confidential case reporting form allows health care providers and lab directors to meet the requirements of the law by reporting occupational and/or injuries to the New Mexico Occupational Health Surveillance Program (OHSP) within 24 hours. Additional instructions for reporting a case are contain within the document.



Photo of the publication cover. Medical Cannabis Personal Production Application Medical Cannabis Program - Form March 13, 2018

Qualified Patients with current valid enrollment who want to produce medical cannabis for themselves may complete the Personal Production Application and submit it with a copy of your New Mexico driver's license or state identification card and the license fee.



Photo of the publication cover. Medical Cannabis Caregiver Application Medical Cannabis Program - Form March 13, 2018

To enroll as a personal caregiver for an existing medical cannabis patient(s), you must complete this application and submit it with a copy of your New Mexico driver's license or state identification card and background check.



Photo of the publication cover. Medical Cannabis Patient Application Medical Cannabis Program - Form March 13, 2018

The application for first time and returning patients is the same. Please complete this form and submit it with a copy of your current New Mexico driver's license or state identification card. Temporary ID’s are not accepted. You must provide documentation to support diagnosis of the medical condition, past treatments, potential health benefit vs. risk of Medical Cannabis and the date(s) of service.



Photo of the publication cover. Birthing Workforce Retention Fund Application Form Midwife Roster - Form March 8, 2018

Use this form to provide birthing workforce retention fund information to the New Mexico Department of Health.



Photo of the publication cover. HCBS Acknowledgement for Consumer Rights and Freedoms Form Developmental Disabilities - Form March 7, 2018

Signing this form is acknowledgement that the HCBS Consumer Rights and Freedoms document has been received, explained and signed.

HCBS Consumer Rights and Freedoms



Photo of the publication cover. Breath Alcohol Instrument Peripheral Ordering Breath Alcohol - Form March 1, 2018

Breath Alcohol Instrument Peripheral Ordering



Photo of the publication cover. DDW Case Management: OR Budget Worksheet for Adults Sample Developmental Disabilities Waiver - Form February 23, 2018

DDW Case Management: OR Budget Worksheet for Adults Sample



Photo of the publication cover. VFC Approved School Sites - Needle, Syringe, & e-kit Order Form Immunization - Form February 23, 2018

This form is to be used for needles/syringes, and e-kit medications and is for Vaccines for Children Approved Sites Only.



Photo of the publication cover. VFC Middle School Vaccination Letter/Permission Form Immunization - Form February 23, 2018

This is the letter addressed to parents or legal guardians to determine whether or not a child is to be vaccinated at school. This letter is to be sent out with the VFC school immunization consent form.

VFC Middle School Vaccination Letter/Permission Form (Spanish)



Photo of the publication cover. Medical Emergency Response Plan Form (side-by-side format) Clinical Services - Form February 22, 2018

Medical Emergency Response Plan Form (side-by-side format)



Photo of the publication cover. Medical Emergency Response Plan Form (standard format) Clinical Services - Form February 22, 2018

Medical Emergency Response Plan Form (standard format)



Photo of the publication cover. VFC Troubleshooting Record Form Immunization - Form February 16, 2018

This form should be used to report out of range temperature incidents and submit a troubleshooting record to the vaccines for children program.



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