Forms

Note: submission requires pre-approval from an on call epidemiologist at 505-827-0006

ACQ Authorization Form for Appointments

ACQ Application Questionnaire (8/2019)

Please complete this information on every newborn receiving hepatitis B immune globulin (HBIG).

DDW/MFW Renewing Provider Application Forms

DDW/MFW Provider Application Packet

This form may be used by individuals requesting a religious or medical exemption to immunization for their children whom attend any public, private or parochial pre-school, kindergarten, elementary, secondary school, or home school and for children attending daycare of childcare facilities.

This form may be used by individuals requesting a religious or medical exemption to immunization for their children whom attend any public, private or parochial pre-school, kindergarten, elementary, secondary school, or home school and for children attending daycare of childcare facilities.

Certificate of Exemption FAQ

This is the fillable form reference tool for THERAP.

Fill out this application to apply for admission to the New Mexico State Veterans' Home.

NMSVH Intake Sheet

The New Mexico J-1 waiver program allows foreign medical graduates to obtain a waiver of their 2 year foreign residence requirement in exchange for a commitment to practice in underserved areas of New Mexico after the completion of their training.

Attachment A
Attachment C

Use this form to request general biological clinical analysis.

Clinical Test Request Form (Pre-Populated for Zika Virus)

Qualified Patients with current valid enrollment who want to produce medical cannabis for themselves may complete the Personal Production Application and submit it with a copy of your New Mexico driver's license or state identification card and the license fee.

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.

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.

FIT Developmental Specialist Recertification Application

FIT Developmental Specialist Initial Certification Application

Transition to Employment Application