Forms

The New Mexico Health Service Corps provides stipends to eligible health professionals during their last two years of training or residency who, in turn, enter into contract with the Department of Health to provide (when licensed) health service for a minimum of two years (1600 hours per year) in an underserved area of New Mexico. This document lists a person who is not a relative and who is in a position to comment on the applicant’s academic and/or professional ability.

CDC-Revised document as COVID-19 Vaccine Program Provider Agreement

CDC-Supplemental document as COVID-19 Vaccine Redistribution Agreement

This form should be used to authorize the disclosure of health information for patients.

Therap Caseload Tool (How-To Check, Add, and Remove Individuals)

Assignment of Benefits and Consent Form

COVID-19 In-Person Visitation Application

COVID-19 In-Person Visitation Application Template
COVID-19 In-Person Visitation Application FAQ

Mi Via Self-Directed Waiver Consultant Application Packet

To enroll as a personal caregiver for an existing medical cannabis patient(s), you must complete this application and submit it with a copy of your New Mexico driver's license or state identification card and background check.

The application for first time and returning patients is the same. Please complete this form and submit it with a copy of your current New Mexico driver's license or state identification card. Temporary ID’s are not accepted. You must provide documentation to support diagnosis of the medical condition, past treatments, potential health benefit vs. risk of Medical Cannabis and the date(s) of service.

Regional Office Request for Assistance

Regional Office Request for Assistance Instructions

NMDOH Internship Application

After a period of three years from the effective date of placement on the registry, an individual on the registry may petition for removal from the registry. The petition shall be sent to the custodian of the registry.

Sliding Fee Scale

If your personal information has changed, you have moved, new phone number, stopped using Medical Cannabis, you have lost or damaged your card, you must complete this form and submit it with your current Patient ID Card and/or Personal Production License Card and a copy of your New Mexico driver's license or state identification card.

LM Annual Report

User security and confidentiality agreement for the New Mexico Statewide Immunization Information System.

Electronic Certifier Training Request Form

Compliant Reporting Poster 2022

OCHW Registration Form - Deadline Feb 4, 2022