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. Naloxone Medication Log for Secure Designated Storage Location – Sample Harm Reduction - Form January 19, 2017

This an example of how to complete the log (required by regulation) tracking naloxone medication.



Photo of the publication cover. Naloxone Medication Log for Secure Designated Storage Location Harm Reduction - Form January 19, 2017

This is a log (required by regulation) tracking naloxone medication.



Photo of the publication cover. Naloxone Inventory and Order Form Harm Reduction - Form January 17, 2017

Use this form to manage inventory and orders of naloxone.



Photo of the publication cover. Community Health Worker Certification through Grandfathering Application Community Health Workers - Form January 13, 2017

This is the application detailing required documentation, eligibility requirements, and submission guidelines for Community Health Worker Certification through Grandfathering.

Certificación de los Trabajadores de Salud Comunitarios a Través de Derechos Adquiridos



Photo of the publication cover. NMHSC Stipend Application for 2018 Primary Care & Rural Health - Form January 11, 2017

The New Mexico Health Service Corps provides stipends to eligible health professionals during their last two years of training or residency who, in turn, enter into contract with the Department of Health to provide (when licensed) health service for a minimum of two years (1600 hours per year) in an underserved area of New Mexico. This document is the application for this program.



Photo of the publication cover. NMHSC Stipend Applicant Reference Report for 2018 Primary Care & Rural Health - Form January 9, 2017

The New Mexico Health Service Corps provides stipends to eligible health professionals during their last two years of training or residency who, in turn, enter into contract with the Department of Health to provide (when licensed) health service for a minimum of two years (1600 hours per year) in an underserved area of New Mexico. This document lists a person who is not a relative and who is in a position to comment on the applicant’s academic and/or professional ability.



Photo of the publication cover. VFC Northeast Region Temperature Log Form Immunization - Form December 14, 2016

Counties: Colfax, Guadalupe, Harding, Los Alamos, Mora, Rio Arriba, San Miguel, Santa Fe, Taos, and Union



Photo of the publication cover. JOE Instructor Coordinator Renewal Application EMS Committees - Form December 14, 2016

This is the renewal application for existing inctructor/coordinators.



Photo of the publication cover. JOE Instructor Coordinator Initial Application EMS Committees - Form December 14, 2016

This is the initial application for new inctructor/coordinators.



Photo of the publication cover. Health Facility Complaint Investigation Five Day Follow-up Report Form Health Facility Complaints - Form December 8, 2016

This form is for a five-day follow up report on licensed health facility complaint investigations.



Photo of the publication cover. Community Program ANE Reporting Form Community Programs - Form December 8, 2016

Use this form to report Abuse, Neglect & Exploitation in community-based medicaid waiver programs.



Photo of the publication cover. VFC Middle School Vaccination Letter/Permission Form Immunization - Form December 5, 2016

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. VFC School Immunization Consent Form Immunization - Form December 5, 2016

This is the form to be completed by parents or guardians indicating whether or not a child is to be vaccinated at school.

VFC School Immunization Consent Form (Spanish)



Photo of the publication cover. RHCPTC Tax Credit Application 2016 Primary Care & Rural Health - Form December 1, 2016

Rural health care practitioner tax credit program application.



Photo of the publication cover. Family Planning Educational Resources Order Form Family Planning - Form November 10, 2016

Use this form to order family planning educational resources.



Photo of the publication cover. EMS Renewal Licensing Application EMS Licensing - Form November 10, 2016

This form should be used for renewal applicants.

Renewal Licensing Instructions



Photo of the publication cover. Naloxone Enrollment and Record of Use Form Harm Reduction - Form November 9, 2016

Use this form to enroll and record use of naloxone.



Photo of the publication cover. Chemistry Analysis Request Form Chemistry - Form November 9, 2016

Use this form to request general chemistry analysis.

Instructions
Drop Down Menus



Photo of the publication cover. VFC Metro Region Temperature Log Form Immunization - Form November 8, 2016

County: Bernalillo



Photo of the publication cover. VFC Northwest Region Temperature Log Form Immunization - Form November 8, 2016

Counties: Cibola, McKinley, San Juan, Sandoval, Torrance, and Valencia

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