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Photo of the publication cover. NMHSC Stipend Program Guidelines for 2024 - 2025 Primary Care & Rural Health - Form July 9, 2024

NMHSC Stipend Program Guidelines for 2024 - 2025



Photo of the publication cover. NMHSC Stipend Application for 2024 - 2025 Primary Care & Rural Health - Form July 9, 2024

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 is the application for this program.



Photo of the publication cover. Drug-Facilitated Sexual Assault Toxicology Request Form Toxicology - Form July 1, 2024

Use this form to request drug-facilitated sexual assault toxicology analysis.



Photo of the publication cover. NMSIIS Decision to Remove Record Immunization - Form June 14, 2024

This form is used by a patient/parent/legal guardian to remove records from the New Mexico Statewide Immunization Information System.

NMSIIS Decision to Remove Record (Spanish)



Photo of the publication cover. NMSIIS User Security and Confidentiality Agreement 2024 Immunization - Form June 5, 2024

NMSIIS User Security and Confidentiality Agreement 2024



Photo of the publication cover. NMSIIS Organization Security and Confidentiality Agreement 2024 Immunization - Form June 5, 2024

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



Photo of the publication cover. Certificate of Exemption from Immunization (English) Immunization - Form June 5, 2024

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



Photo of the publication cover. Certificate of Exemption from Immunization (Spanish) Immunization - Form June 5, 2024

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.



Photo of the publication cover. Affidavit of Review of a Certified New Mexico Birth Certificate Vital Records - Form June 4, 2024

This form is to be used by agencies and organizations to document eligibility. This should not be accepted in place of a birth certificate.



Photo of the publication cover. Authorization to Disclose Health Information (English) Security Office - Form June 4, 2024

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)



Photo of the publication cover. NMSIIS Decline to Participate Form Immunization - Form June 3, 2024

This form is used by a patient/parent/legal guardian to decline to participate in the New Mexico Statewide Immunization Information System.

NMSIIS Decline to Participate (Spanish)



Photo of the publication cover. Client Rights Grievance Process and ANE Reporting Form Developmental Disabilities Waiver - Form May 30, 2024

Client Rights Grievance Process and ANE Reporting Form



Photo of the publication cover. Sample Collection Kit Order Form Kit Preparation - Form March 27, 2024

Use this form to order sample collection kits.



Photo of the publication cover. DDW Field Tools – Case Management - CM Individual Specific Interview Survey Tool Quality Management - Form March 25, 2024

Case Management - General and Individual Specific Interview Survey Tool



Photo of the publication cover. Mi Via Administrative Requirements and Interview Quality Management - Form March 25, 2024

Mi Via Administrative Requirements and Interview



Photo of the publication cover. DDW Field Tools – Case Management - Admin Interview and Requirements Tool Quality Management - Form March 25, 2024

Case Management - Administrator Interview Tool



Photo of the publication cover. DDW Field Tools – Case Management - Billing Tool Quality Management - Form March 25, 2024

Case Management - Billing Tool



Photo of the publication cover. DDW Field Tools – Case Management - Agency Individual Record Review Survey Tool Quality Management - Form March 25, 2024

Case Management - Individual Record Review Survey Tool



Photo of the publication cover. DDW Field Tools – Case Management - EAR, CCHS & Training Tool Quality Management - Form March 25, 2024

Case Management - Surveyor Instructions



Photo of the publication cover. Mi Via Requirements for Consultants Quality Management - Form March 25, 2024

Mi Via Requirements for Consultants

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