Forms
VFC Provider NM Health Passport Order Form
Immunization - Form
April 18, 2016
This form allows providers to order VFC supplies.
Arbovirus Case Reporting Form
Zoonotic Diseases - Form
October 14, 2015
Use this form to report cases of West Nile virus to the New Mexico Department of Health.
EMD Background Screening Affidavit of No Known Criminal History
EMS Licensing - Form
September 11, 2015
This form is an affidavit of no known criminal history for use by applicants.
Animal Test Request Form
Biology - Form
March 16, 2015
Use this form to request animal specimen analysis.
Report of Audiological Results Form
Children's Medical Services - Form
December 9, 2014
This form is used by audiologists to report their audiological results to the New Mexico Department of Health after screening a newborn’s hearing.
EMS Trauma Hospital Reporting Form
EMS Trauma Care Program - Form
October 1, 2014
This form should be used by emergency medical services hospitals to report community outreach and prevention activities.
EMS Cardiac Arrest Response AED Program Registration Packet
EMS Targeted Cardiac Response Program - Form
September 5, 2014
This packet should be used by any person or entity operating or creating an automated external defibrillator program within the state of New Mexico. This packet also contains several other items including a notification of program form, usage data collection form, and a checklist of guidelines for establishing a program.
Substitute W-9 Form
Public Relations - Form
August 27, 2014
This form should be used to provide a substitute W-9 form to the New Mexico department of finance and administration's financial control division.
VFC Transport Temperature Log Form for Frozen Vaccines
Immunization - Form
June 27, 2014
Complete this log when transporting vaccines to an alternate or back-up freezer.
Primary Care Capital Fund Application
Primary Care & Rural Health - Form
May 13, 2014
Primary and capital fund application for financial assistance to the New Mexico Department of Health and New Mexico finance authority.
Pesticide Illness Reporting
Occupational Health Surveillance - Form
April 2, 2014
This form should be used by all healthcare professionals to report pesticide related illness and injury of workers in New Mexico to the Occupational Health Surveillance Program. It includes a list of questions you can ask your patients and the symptoms of pesticide exposure are also listed in both English and Spanish.
Air Quality Analysis Request Form
Air and Heavy Metals - Form
March 18, 2014
Use this form to request air quality analysis.
Acknowledgment of Paternity Statement
Vital Records - Form
February 28, 2014
Establishment of paternity means the establishment of the parent-child relationship. This Acknowledgment of Paternity (AOP) shall be signed under penalty of perjury by the mother and by the man seeking to establish paternity.
EMS Trauma Registry Username & Password Request Form
EMS Trauma Care Program - Form
February 25, 2014
This form should be used to request a username and password for the emergency medical services trauma registry.
Fort Bayard Financial Disclosure Form
Fort Bayard Medical Center - Form
December 19, 2013
This financial disclosure form is required for admission to Fort Bayard Medical Center.
Fort Bayard Financial & Payment Contract Form
Fort Bayard Medical Center - Form
December 19, 2013
This financial payment contract form is required for admission to Fort Bayard Medical Center.
Fort Bayard Patient Demographics Form
Fort Bayard Medical Center - Form
December 19, 2013
This patient demographics form is required for admission to Fort Bayard Medical Center.
EMS RETRACS TPIC Performance Improvement Reporting Form
EMS Committees - Form
November 27, 2013
This form should be used to report performance improvement issues.