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. VFC Routine Vaccine Management Plan Immunization - Form November 22, 2017

The New Mexico VFC Program requires each practice to develop and maintain a Routine Vaccine Management Plan. Properly completing this template will meet the VFC Program requirement for VFC Program participants to have written vaccine storage and handling plans.



Photo of the publication cover. VFC Emergency Vaccine Management Plan Immunization - Form November 22, 2017

The New Mexico VFC Program requires each practice to develop and maintain an Emergency Vaccine Management Plan. Properly completing this template will meet the VFC Program requirement to have a written plan for storage and handling procedures in an emergency.



Photo of the publication cover. VFC Northeast Region Temperature Log Form Immunization - Form November 16, 2017

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



Photo of the publication cover. VFC Program Data Logger Timeline and Checklist Vaccines for Children - Form November 14, 2017

This document is for providers: guidelines and important dates for the transition to digital data loggers.



Photo of the publication cover. Adult Nursing Services: Prior Authorization Request Form Clinical Services - Form November 3, 2017

Adult Nursing Services: Prior Authorization Request Form

Prior Authorization Request Instructions



Photo of the publication cover. Assistive Technology: Budget-Based ATF Fund Application Form Clinical Services - Form October 30, 2017

Assistive Technology: Budget-Based ATF Fund Application Form

Budget-Based ATF Fund Application Instructions



Photo of the publication cover. EMS Local Funding Program Annual Service Report Form EMS Fund Act - Form October 25, 2017 - January 20, 2018

This form should be used to report annual service for the local funding grant program.



Photo of the publication cover. EMS Local Funding Program Application Form EMS Fund Act - Form October 25, 2017 - January 20, 2018

This form should be used to apply for the local funding grant program.



Photo of the publication cover. JOE Instructor Coordinator Transfer Request EMS Committees - Form October 20, 2017

This is a document to be filled out when an Instructor Coordinator is changing his/her training institution affiliation or adding an affiliation with a training institution.



Photo of the publication cover. EMS TSFA Trauma System Development Application FY19 EMS Committees - Form October 20, 2017

This document describes the required process for eligible trauma system development projects to receive funding. Funding will be issued through a separate agreement between each approved organization and the New Mexico Department of Health Memorandum of Agreement process.



Photo of the publication cover. HCBS Registration Form Eligibility Determination - Form October 18, 2017

HCBS Registration Form



Photo of the publication cover. Adult Vaccine Order Form Immunization - Form October 10, 2017

Healthcare providers may use this form to order adult vaccines.



Photo of the publication cover. Adult Vaccine Return Form Immunization - Form October 10, 2017

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



Photo of the publication cover. Asthma Pictoral Action Plan Asthma - Form October 10, 2017

The pictorial asthma action plan is a patient education tool intended to supplement the asthma action plan. It is designed to engage children and families in asthma self-management and improve overall measures of asthma control.



Photo of the publication cover. Asthma Data Request Form Asthma - Form October 10, 2017

This form is used to collect the most recent asthma related data critical for policy development and program planning in the state.



Photo of the publication cover. PASRR Level 1 Identification Screen Form Pre-Admission Screening & Resident Review - Form October 4, 2017

Preadmission Screening and Resident Review Level I Identification Screen



Photo of the publication cover. Immunization Assessment Worksheet for 7th Grade Immunization - Form September 8, 2017

Immunization Assessment Worksheet for 7th Grade



Photo of the publication cover. Immunization Assessment Worksheet for Kindergarten Immunization - Form September 8, 2017

Immunization Assessment Worksheet for Kindergarten



Photo of the publication cover. EMS Reciprocity Licensing Application EMS Licensing - Form August 15, 2017

This form should be used for reciprocity applicants.

Reciprocity Licensing Instructions



Photo of the publication cover. EMS Re-Entry Licensing Application EMS Licensing - Form August 15, 2017

This form should be used for re-entry applicants.

Re-Entry Licensing Instructions

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