Forms
Eddy, Lea, Lincoln, and Roosevelt
Catron, Dona Ana, Grant, Hidalgo, Luna, Otero, Sierra, and Socorro
Civil Money Penalty (CMP) Reinvestment Application Template
Protocol Section 7: Overall Scoring
Protocol Section 6: Individual & Guardian Interviews
Protocol Section 4: Employment/Day
Protocol Section 3: Case Management
Protocol Section 2: Nurse/Therapy/BSC Interviews
Protocol Section 1: Information Gathering
2014 IQR Community Practice Review Protocol
2016 IQR Mi Via Review Protocol
Resource Request (ics 213 RR), Adapted for NM SEOC - Example
Resource Request (ics 213 RR), Adapted for NM SEOC - Blank
Use this form to request an informal reconsideration of findings.
Breath Alcohol Instrument Peripheral Ordering
DDW/MFW/SW Statement of Assurances
SW Final Rule Attestation Letter
The application for first time and returning patients is the same. Please complete this form and submit it with a copy of your current New Mexico driver's license or state identification card. Temporary ID’s are not accepted. You must provide documentation to support diagnosis of the medical condition, past treatments, potential health benefit vs. risk of Medical Cannabis and the date(s) of service.
The New Mexico J-1 waiver program allows foreign medical graduates to obtain a waiver of their 2 year foreign residence requirement in exchange for a commitment to practice in underserved areas of New Mexico after the completion of their training.
Use this form to request priority of case status.