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. JOE Education Designee Form EMS Committees - Form May 19, 2017

This form is applicable for the following entities to utilize: the director and medical director of the academy, and the director and medical director of each approved emergency medical services training program, the state emergency medical services medical director, and the bureau chief whose designee shall serve without vote.



Photo of the publication cover. JOE Proxy Form EMS Committees - Form May 19, 2017

This form is applicable for the following entities to utilize: Each emergency medical services regional office training coordinator and providers from the three highest levels of licensure, who are appointed by the secretary from a list proposed by the statewide EMS advisory committee.



Photo of the publication cover. EMS Reciprocity Licensing Application EMS Licensing - Form May 3, 2017

This form should be used for reciprocity applicants.

Reciprocity Licensing Instructions



Photo of the publication cover. EMS Renewal Licensing Application EMS Licensing - Form May 3, 2017

This form should be used for renewal applicants.

Renewal Licensing Instructions



Photo of the publication cover. EMS Initial Licensing Application EMS Licensing - Form May 3, 2017

This form should be used for initial applicants.

Initial Licensing Instructions



Photo of the publication cover. EMS Re-Entry Licensing Application EMS Licensing - Form May 3, 2017

This form should be used for re-entry applicants.

Re-Entry Licensing Instructions



Photo of the publication cover. Adult Vaccine Order Form Immunization - Form May 2, 2017

Healthcare providers may use this form to order adult vaccines.



Photo of the publication cover. VFC Vaccine Return Form Immunization - Form April 21, 2017

This form is used to return vaccines and to track your inventory. Vaccines that are returned are then cleared from your inventory. Complete and fax this form to the NM VFC Program before you return any vaccines.



Photo of the publication cover. VFC Contact Information Change Form Immunization - Form April 14, 2017

The contact information you provided on the Provider Agreement is used by the State VFC Program to communicate alerts, updates, announcements, and reminders. You are strongly encouraged to check your email frequently for updates from the VFC Program.



Photo of the publication cover. Family Planning Sterilization Provider Evaluation Form Family Planning - Form April 11, 2017

Use this form to evaluate a steralization provider.



Photo of the publication cover. Notifiable Condition Reporting Form Infectious Disease Epidemiology - Form April 4, 2017

Use this form to report notifiable conditions to the department of health.



Photo of the publication cover. New Mexico J-1 Waiver Application 2018 Primary Care & Rural Health - Form April 3, 2017

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. Chemistry Analysis Request Form Chemistry - Form March 14, 2017

Use this form to request general chemistry analysis.

Instructions
Drop Down Menus



Photo of the publication cover. Naloxone Standing Order Form Opioid Safety - Form March 7, 2017

This is the document used to order Naloxone HCI Solution, Narcan Nasal Spray, or Evzio.



Photo of the publication cover. Adult Vaccine Consent Form Immunization - Form March 6, 2017

This form may be used by adult patients aged 19 and older to provide vaccination consent to a healthcare provider.

Adultos Vacuna Formulario de Consentimiento



Photo of the publication cover. Adult Vaccine Return Form Immunization - Form March 6, 2017

This form is used by Healthcare providers to return Adult Vaccines.



Photo of the publication cover. Birthing Workforce Retention Fund Application Form Midwife Roster - Form March 2, 2017

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



Photo of the publication cover. Admission Application for New Mexico State Veterans' Home Veterans' Home - Form February 23, 2017

Fill out this application to apply for admission to the New Mexico State Veterans' Home.



Photo of the publication cover. VFC 2017 New Provider Enrollment Form Immunization - Form February 16, 2017

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. NMSIIS Training Request Form Immunization - Form February 14, 2017

Interested in NMSIIS training? Please ask your site supervisor to download and complete this form.

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