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. 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. EMS Local Funding Program Annual Service Report Form EMS Fund Act - Form November 22, 2016 - January 21, 2017

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 November 17, 2016 - January 21, 2017

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



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



Photo of the publication cover. VFC Vaccine Return Form Immunization - Form November 3, 2016

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 Vaccine Transfer Form Immunization - Form November 3, 2016

This form applies only to vaccines provided by the NM Vaccines for Children Program. Use only for transferring vaccine to another NM VFC Provider. Transfer vaccines three months before expiration date.



Photo of the publication cover. VFC Troubleshooting Record Form Immunization - Form November 3, 2016

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



Photo of the publication cover. EMS TSFA Trauma System Development Application FY18 EMS Committees - Form November 1, 2016

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. Initial Contact Letter Strategic National Stockpile - Form October 19, 2016

For Local POD Planning with Local Law Enforcment Agencies



Photo of the publication cover. Request and Resupply Intrastate Medical Countermeasures Strategic National Stockpile - Form October 19, 2016

POD Resupply Request - Standard Operating Procedure



Photo of the publication cover. Director Operational Briefing Example Strategic National Stockpile - Form October 19, 2016

POD Director - Operational Briefing



Photo of the publication cover. Confidentiality Agreement Strategic National Stockpile - Form October 19, 2016

The purpose of this document is to specify the requirements for the acceptable use and/or disclosure of protected health information by members of the New Mexico Department of Health workforce.



Photo of the publication cover. Volunteer Information Summary Strategic National Stockpile - Form October 19, 2016

Volunteer Information Form



Photo of the publication cover. Volunteer Policy Agreement Strategic National Stockpile - Form October 19, 2016

Volunteer Policy and Agreement Form



Photo of the publication cover. ICS 308A Volunteer Addendum - Resource Request Strategic National Stockpile - Form October 19, 2016

Volunteer Addendum - Resource Request

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