Forms

This form should be used to report out of range temperature incidents and submit a troubleshooting record to the vaccines for children program.

Use this form to provide consent for mirena intrauterine device.

Consentimiento de Levonorgestrel Dispositivo Intrauterino

Use this form to provide consent for paragard intrauterine device.

Consentimiento de Paragard Dispositivo Intrauterino

Use this form to provide consent for implanon nexplanon.

Consentimiento de Implante Anticonceptivo

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. If you are a person with a disability and you require this authorization in an alternative format or require a special accommodation to complete this form, you may request assistance from staff at any DOH location or from the DOH Chief Privacy Officer.

Authorization to Disclose Health Information (Spanish)

New Mexico Nurse Aide Training and Registry Reciprocity Form

All STD cases diagnosed or treated in New Mexico are required by law to be reported to the STD Program in Santa Fe. Additionally, any medical laboratory anywhere in the United States performing testing for New Mexico must report positive results to the New Mexico STD Program in Santa Fe.

Therapy Services: Discontinuation of Therapy Report (Template)

This form may be used by adult patients aged 19 and older to provide vaccination consent to a healthcare provider.

Adultos Vacuna Formulario de Consentimiento

This form allows you to provide immunization information for entry into NMSIIS.

VFC Vacuna Forma Administración (Parte B)

Prefilled Specimen Submission Form for norovirus testing (raw stool)

Prefilled Specimen Submission Form for enteric bacteria testing (transport media)

This form should be used for renewal applicants.

Renewal Licensing Instructions

This is the form to be completed by parents or guardians indicating whether or not a child is to be vaccinated at school.

VFC School Immunization Consent Form (Spanish)

VaxViewNM Demographic and Contact Information Form

Contact your regional office to obtain application approval to ensure it is complete. It is not the regions responsibility to send these applications to the bureau, unless they are complete.

EMS Fund Act FY21 Special Projects Local System Improvement Guide

Contact your regional office to obtain application approval to ensure it is complete. It is not the regions responsibility to send these applications to the bureau, unless they are complete.

EMS Fund Act FY21 Special Projects Statewide System Improvement Guide

Contact your regional office to obtain application approval to ensure it is complete. It is not the regions responsibility to send these applications to the bureau, unless they are complete.

EMS Fund Act FY21 Special Projects Vehicle Purchase Guide
EMS Fund Act Vehicle List Form

ACQ Authorization Form for Appointments

ACQ Application Questionnaire (8/2019)