Forms

Midwife Complaint Form Certified Nurse Midwives and Licensed Midwives - Form January 12, 2021

Use this form to file a complaint against a midwife.

NMSIIS User Security and Confidentiality Agreement Immunization - Form January 4, 2021

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

NMSIIS Participant Organization Security and Confidentiality Agreement Immunization - Form January 4, 2021

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

NMSIIS Decision to Remove Record Immunization - Form January 4, 2021

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

NMSIIS Decline to Participate Form Immunization - Form January 4, 2021

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

COVID-19 Vaccine Consent Form Spanish Immunization - Form December 18, 2020

This form should be used as Consent for COVID-19 Vaccinations

General Clinical Request Form Scientific Laboratory - Form December 15, 2020

SLD General Clinical Request Form v. 4.1

VFC COVID-19 Troubleshooting Record Form Immunization - Form December 15, 2020

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

Credentialing COVID-19 Providers Form 2019 Novel Coronavirus - Form December 10, 2020

Credentialing COVID-19 Providers Form

EMS Local Funding Program Application Form FY22 EMS Fund Act - Form November 6, 2020

EMS Local Funding Program Application Form

EMS Local Funding Program Annual Service Report Form FY22 EMS Fund Act - Form November 6, 2020

EMS Local Funding Program Annual Service Report Form

EMS Local Funding Program Application Form EMS Fund Act - Form November 6, 2020 - January 24, 2021

This form should be used to apply for the local funding grant program.

EMS Local Funding Program Annual Service Report Form EMS Fund Act - Form November 6, 2020 - January 24, 2021

This form should be used to report annual service for the local funding grant program.

Verification of Funds Form Supports Waiver - Form November 3, 2020

Verification of Funds Form

New Laboratory Application Medical Cannabis Producers & Distributors - Form October 29, 2020

MCP New Laboratory Application.

DDW Case Management Form : HP_10.14.2020 Developmental Disabilities Waiver - Form October 20, 2020

DDW Case Management:HP_10.14.2020

EMS TSFA Trauma System Development Application FY22 EMS Committees - Form October 13, 2020

This document describes the required process for eligible trauma system development projects to receive funding. Funding will be issued through a separate agreement between each approved organization and the New Mexico Department of Health Memorandum of Agreement process.