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Photo of the publication cover. EMS Trauma Registry Username & Password Request Form EMS Trauma Care Program - Form February 25, 2014

This form should be used to request a username and password for the emergency medical services trauma registry.



Photo of the publication cover. Fort Bayard Financial Disclosure Form Fort Bayard Medical Center - Form December 19, 2013

This financial disclosure form is required for admission to Fort Bayard Medical Center.



Photo of the publication cover. Fort Bayard Financial & Payment Contract Form Fort Bayard Medical Center - Form December 19, 2013

This financial payment contract form is required for admission to Fort Bayard Medical Center.



Photo of the publication cover. Fort Bayard Patient Demographics Form Fort Bayard Medical Center - Form December 19, 2013

This patient demographics form is required for admission to Fort Bayard Medical Center.



Photo of the publication cover. EMS RETRACS TPIC Performance Improvement Reporting Form EMS Committees - Form November 27, 2013

This form should be used to report performance improvement issues.



Photo of the publication cover. EMS Medical Orders for Scope of Treatment Form EMS Advance Directives - Form November 21, 2013

This form should be used by a physician to outline a plan of care respecting the patient’s wishes concerning care at life’s end.

EMS Medical Orders for Scope of Treatment Instructions



Photo of the publication cover. HIV/AIDS Confidential Case Reporting Form HIV Surveillance & Epidemiology - Form October 17, 2013

Use this form to confidentially report a case of HIV/AIDS.



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. 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 Resources, Publications and Archives - 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.

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