Forms

NMHSC Stipend Applicant Reference Report for 2023 Primary Care & Rural Health - Form July 3, 2023

NMHSC Stipend Applicant Reference Report for 2023

HIV/AIDS Confidential Case Reporting Form HIV Surveillance & Epidemiology - Form June 27, 2023

Use this form to confidentially report a case of HIV/AIDS.

CNA Reciprocity Form Program Operations - Form June 21, 2023

CNA Reciprocity Form

Community Health Worker Continuing Education Unit Provider Application Community Health Workers - Form June 21, 2023

This is the application to become an approved Continuing Education Unit Provider.

Community Health Worker State Certification Renewal Application Community Health Workers - Form June 21, 2023

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

IR-8000 Operator Training Request Form Breath Alcohol - Form June 14, 2023

Use this form to request test operator training.

IR-8000 Key Operator Training Request Form Breath Alcohol - Form June 14, 2023

Use this form to request key operator training.

Breath Alcohol Training Cancellation Notification Form Breath Alcohol - Form June 14, 2023

Use this form to cancel training requests.

VFC Provider Staff Change of Contact and uploading Training Immunization - Form April 13, 2023

VFC Provider Staff Change of Contact and uploading Training

VFC Physician Signing Agreement Change of Contact Immunization - Form April 13, 2023

VFC Physician Signing Agreement Change of Contact

VFC New Provider Application Immunization - Form April 13, 2023

All VFC providers are required to submit this annual VFC certification form in order to continue receiving VFC vaccines.

VFC Instructions on Digital Signature and Attaching License

VFC Provider NM Health Passport Order Form Immunization - Form April 13, 2023

This form allows providers to order VFC supplies.

Cover Sheet for Audiological Reports Children's Medical Services - Form April 11, 2023

Cover Sheet for Audiological Reports

Fillable Cover Sheet for Audiological Reports

Pharmacist Telehealth Consent Form Family Planning - Form March 21, 2023

Pharmacist Telehealth Consent Form

Pharmacist Telehealth Consent Form
Pharmacist Telehealth Consent Form - Spanish

MVAC Membership Application Advisory Council on Quality - Form March 20, 2023

MVAC Membership Application

Child Lead Exposure Questionnaire Lead Poisoning Prevention - Form March 14, 2023

Use this questionnaire to help you and your health care provider to decide if your child needs a blood test for lead.

Cuestionario de Exposición al Plomo Para Niños

Prenatal Lead Risk Questionnaire Lead Poisoning Prevention - Form March 14, 2023

This questionnaire provides a list of questions intended to gather all the essential information required to help those who are pregnant or planning pregnancy determine if they need a blood test for lead.

Cuestionario de riesgo prenatal plomo