Forms
Request to Change Gender Designation on a Birth Certificate: 14 Years of Age or Over Consent Form
Vital Records - Form
October 28, 2019
This additional form is required to request a gender change on a birth certificate if the registrant is 40 years of age or over.
Authorization to Disclose Health Information (English)
Security Office - Form
October 8, 2019
This authorization allows the Department of Health (DOH) to disclose confidential health information about you. The authorization may be revoked. It will remain in effect for six (6) months unless a different time is stated. You are entitled to a copy of the completed authorization. There may be fees charged for any copying associated with this request. If you are a person with a disability and you require this authorization in an alternative format or require a special accommodation to complete this form, you may request assistance from staff at any DOH location or from the DOH Chief Privacy Officer.
STD Case Reporting Form
Sexually Transmitted Diseases - Form
September 25, 2019
All STD cases diagnosed or treated in New Mexico are required by law to be reported to the STD Program in Santa Fe. Additionally, any medical laboratory anywhere in the United States performing testing for New Mexico must report positive results to the New Mexico STD Program in Santa Fe.
Prefilled Specimen Submission Form for norovirus testing (raw stool)
Norovirus - Form
September 9, 2019
Prefilled Specimen Submission Form for norovirus testing (raw stool)
Prefilled Specimen Submission Form for enteric bacteria testing (transport media)
Norovirus - Form
September 9, 2019
Prefilled Specimen Submission Form for enteric bacteria testing (transport media)
Admission Application for New Mexico State Veterans' Home
Veterans' Home - Form
June 26, 2019
Fill out this application to apply for admission to the New Mexico State Veterans' Home.
Turquoise Lodge Adult Financial Eligibility Form
Turquoise Lodge Hospital - Form
May 10, 2019
This form should be completed to determine financial eligibility for adult patients.
Asthma Action Plan for Schools
Asthma - Form
February 12, 2019
This action plan form was created by the New Mexico Council on Asthma (NMCOA) for school nurses, health care providers and families. It allows for an individual action plan to be developed for each student to ensure proper handling of asthma based on severity.
Asthma Pictorial Action Plan
Asthma - Form
February 12, 2019
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.
Community Health Worker State Certification Specialty Track Advanced Application
Community Health Workers - Form
January 30, 2019
This is the Community Health Worker State Certification Specialty Track Advanced Application.
Aplicación para la Certificación Estatal como Especialistas Avanzados
Community Health Worker State Certification Renewal Application
Community Health Workers - Form
January 30, 2019
This is the application detailing required documentation, eligibility requirements, and submission guidelines for Community Health Worker state certification renewal.
Solicitud de Renovación de Certificación Estatal de Trabajadores de Salud Comunitarios
Community Health Workers State Certification Application
Community Health Workers - Form
January 24, 2019
This is the application detailing required documentation, eligibility requirements, and submission guidelines for Community Health Worker state certification.
Aplicación para la Certificación Estatal de los Trabajadores de la Salud Comunitaria
Sample Collection Kit Order Form
Kit Preparation - Form
November 2, 2018
Use this form to order sample collection kits.
Track Your Child's Development - Checklist
Maternal & Child Health Epidemiology - Form
October 26, 2018
This is a checklist that allows you to fill out your child's name, age, and date and then check off the milestones your child has already achieved.
EMS CE Renewal Blueprint Refresher Breakdown Sheet
EMS Continuing Education - Form
October 19, 2018
This form is for those who apply for renewal and are being audited. Fill it out to identify the category and quantity of continuing education for the required levels of licensure.
School Consent to Enter Student Records into NMSIIS
Immunization - Form
September 17, 2018
This is a customizable form for use by schools to collect consent from parents so students' historic immunization records may be added to NMSIIS.
Breath Alcohol Training Cancellation Notification Form
Breath Alcohol - Form
September 14, 2018
Use this form to cancel training requests.
Chemistry Analysis Request Form
Chemistry - Form
July 16, 2018
Use this form to request general chemistry analysis.
CMS Telephone Referral Form
Children's Medical Services - Form
April 5, 2018
CMS Telephone Referral Form