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Photo of the publication cover. Audiology Survey from Subcommittee Children's Medical Services - Form September 30, 2013

This survey form helps the New Mexico Early Detection and Intervention advisory council gather current data in order to update the resource list of professionals who provide newborn and pediatric audiology services in our state.



Photo of the publication cover. Physician Reporting Form Children's Medical Services - Form August 13, 2013

This form is used by physicians to report the results of their hearing screen or diagnostic audiological evaluation to the New Mexico Department of Health.



Photo of the publication cover. EMS Parental Consent for EMSFR or EMT-B Licensure Form Emergency Medical Systems - Form June 12, 2013

This form should be used by the parents of children applying for EMSFR or EMT-B licensure.



Photo of the publication cover. Midwife Reporting Form Children's Medical Services - Form April 26, 2013

This form is used by midwives to record their audiological results or to refer parents to a doctor who will follow screen and follow the baby. This form is then submitted to the New Mexico Department of Health.



Photo of the publication cover. Putative Father Registry Inclusion Request Vital Records - Form April 8, 2013

This is a request for inclusion the New Mexico Putative Father Registry. This request is made either voluntarily by a father who hereby gives notice that he intends to claim paternity or has claimed paternity of his child, or involuntarily on the basis of a court order determining paternity.



Photo of the publication cover. Medical Cannabis HIPAA Authorization Medical Cannabis Program - Form March 22, 2013

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.



Photo of the publication cover. Newborn Hearing Screening Checklist Children's Medical Services - Form February 18, 2013

This form helps you track your baby’s hearing, understanding and talking in their first year.

Lista de Verificación de Screening Auditivo Neonatal



Photo of the publication cover. Independent Informal Dispute Resolution Request Form Program Operations - Form January 31, 2013

Use this form to request an independent informal dispute resolution hearing.



Photo of the publication cover. Family Roadmap Children's Medical Services - Form December 19, 2012

This form makes it easy for families to track their baby’s hearing screening follow-up tasks from birth to 6 months old.

Audiencia Newborn Screening Familia Hoja de Ruta



Photo of the publication cover. Birth Record Search Application Vital Records - Form September 28, 2012

Use this form to request a birth certificate.

Solicitud de Acta de Nacimiento



Photo of the publication cover. Death Record Search Application Vital Records - Form September 28, 2012

Use this form to request a death certificate.

Solicitud de Acta de Defunción



Photo of the publication cover. EMS Agency Certification Application Form EMS Agency Certification - Form August 14, 2012

This form should be used by emergency medical rescue programs and emergency dispatch centers to apply for certification.



Photo of the publication cover. Putative Father Registry Search Inquiry Vital Records - Form July 2, 2012

A request for a search of the registry may only be made by a court of competent jurisdiction; a department authorized by law to take actions affecting a child’s health, safety or welfare; the petitioner’s attorney or the mother of the child.



Photo of the publication cover. EMS License Plate Order Form Emergency Medical Systems - Form July 2, 2012

This form should be used to order a special Emergency Medical Services license plate from the New Mexico Motor Vehicles Division.



Photo of the publication cover. EMS Agency Certification Emergency Medical Rescue Inspection Checklist EMS Agency Certification - Form April 17, 2012

This is a checklist for emergency medical rescue program certification.



Photo of the publication cover. Food Analysis Request Form Biology - Form February 22, 2012

Use this form to request food analysis.



Photo of the publication cover. Electronic Transfer of Biology Data Release Form Biology - Form February 22, 2012

Use this form to request the release of confidential patient information data.



Photo of the publication cover. Report of Adoption Vital Records - Form February 17, 2012

This form is required for each adoption decreed in the state of New Mexico.



Photo of the publication cover. Fort Bayard Dietary Interview Form Fort Bayard Medical Center - Form January 10, 2012

This dietary interview form is required for admission to Fort Bayard Medical Center.



Photo of the publication cover. EMS Agency Certification Emergency Medical Dispatch Center Inspection Checklist EMS Agency Certification - Form November 8, 2011

This is a checklist for emergency medical dispatch center certification.

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