Forms
Contraceptive Implant – Consent Form
Family Planning - Form
October 11, 2022
Contraceptive Implant – Consent Form
Contraceptive Implant – Counseling Handout
Family Planning - Form
October 11, 2022
Contraceptive Implant – Counseling Handout
Birth Control Pills COCs – Counseling Handout
Family Planning - Form
October 11, 2022
Birth Control Pills COCs – Counseling Handout
PASRR Level 1 Identification Screen Form
Pre-Admission Screening & Resident Review - Form
September 30, 2022
Preadmission Screening and Resident Review Level I Identification Screen
COVID-19 Vaccine Troubleshooting Report
Immunization - Form
August 24, 2022
COVID-19 Vaccine Troubleshooting Report
VFC School Immunization Consent Form
Immunization - Form
August 17, 2022
This is the form to be completed by parents or guardians indicating whether or not a child is to be vaccinated at school.
VFC Vaccine Administration Form (Part B)
Immunization - Form
August 17, 2022
This form allows you to provide immunization information for entry into NMSIIS.
Hepatitis B Immune Globulin (HBIG) Reporting Form
Perinatal Hepatitis B Prevention - Form
August 9, 2022
Please complete this information on every newborn receiving hepatitis B immune globulin (HBIG).
CDC-Revised document as COVID-19 Vaccine Program Provider Agreement
Immunization - Form
May 18, 2022
CDC-Revised document as COVID-19 Vaccine Program Provider Agreement
CDC-Supplemental document as COVID-19 Vaccine Redistribution Agreement
Immunization - Form
May 18, 2022
CDC-Supplemental document as COVID-19 Vaccine Redistribution Agreement
Turquoise Lodge Authorization to Disclose Health Information Form
Turquoise Lodge Hospital - Form
May 18, 2022
This form should be used to authorize the disclosure of health information for patients.
Therap Caseload Tool (How-To Check, Add, and Remove Individuals)
Clinical Services - Form
April 27, 2022
Therap Caseload Tool (How-To Check, Add, and Remove Individuals)
Assignment of Benefits and Consent Form
Family Planning - Form
April 14, 2022
Assignment of Benefits and Consent Form
COVID-19 In-Person Visitation Application
Health Improvement - Form
March 7, 2022
COVID-19 In-Person Visitation Application
COVID-19 In-Person Visitation Application Template
COVID-19 In-Person Visitation Application FAQ
LM Annual Report
Certified Nurse Midwives and Licensed Midwives - Form
February 3, 2022
LM Annual Report
Electronic Certifier Training Request Form
Vital Records - Form
January 21, 2022
Electronic Certifier Training Request Form
Compliant Reporting Poster 2022
Health Improvement - Form
January 13, 2022
Compliant Reporting Poster 2022
OCHW Registration Form - Deadline Feb 4, 2022
Community Health Workers - Form
January 12, 2022
OCHW Registration Form - Deadline Feb 4, 2022