Forms

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.

Use this form to report Abuse, Neglect & Exploutation in health facilities only if you are a consumer, family member, or general public.

Use this form to request an informal reconsideration of findings.

Use this form to request air quality analysis.

This form should be used to request a username and password for the emergency medical services trauma registry.

This financial disclosure form is required for admission to Fort Bayard Medical Center.

This financial payment contract form is required for admission to Fort Bayard Medical Center.

This patient demographics form is required for admission to Fort Bayard Medical Center.

This form should be used to report performance improvement issues.

This form should be used by a physician to outline a plan of care respecting the patient’s wishes concerning care at life’s end.

EMS Medical Orders for Scope of Treatment Instructions

This survey form helps the New Mexico Early Detection and Intervention advisory council gather current data in order to update the resource list of professionals who provide newborn and pediatric audiology services in our state.

This form is used by physicians to report the results of their hearing screen or diagnostic audiological evaluation to the New Mexico Department of Health.

This form should be used by the parents of children applying for EMSFR or EMT-B licensure.

This is a request for inclusion the New Mexico Putative Father Registry. This request is made either voluntarily by a father who hereby gives notice that he intends to claim paternity or has claimed paternity of his child, or involuntarily on the basis of a court order determining paternity.

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.

This form helps you track your baby’s hearing, understanding and talking in their first year.

Lista de Verificación de Screening Auditivo Neonatal

Use this form to request an independent informal dispute resolution hearing.

This form makes it easy for families to track their baby’s hearing screening follow-up tasks from birth to 6 months old.

Audiencia Newborn Screening Familia Hoja de Ruta

This form should be used by emergency medical rescue programs and emergency dispatch centers to apply for certification.

A request for a search of the registry may only be made by a court of competent jurisdiction; a department authorized by law to take actions affecting a child’s health, safety or welfare; the petitioner’s attorney or the mother of the child.