Forms
EMS Renewal License Continuing Education Breakdown
EMS Continuing Education - Form
October 19, 2018
This form is for those who apply for renewal and are being audited. Fill it out to identify the category and quantity of continuing education for the required levels of licensure.
Birthing Workforce Retention Fund Application Form
Certified Nurse Midwives and Licensed Midwives - Form
October 17, 2018
Use this form to provide birthing workforce retention fund information to the New Mexico Department of Health.
VFC Emergency Vaccine Management Plan
Immunization - Form
October 17, 2018
The New Mexico VFC Program requires each practice to develop and maintain an Emergency Vaccine Management Plan. Properly completing this template will meet the VFC Program requirement to have a written plan for storage and handling procedures in an emergency.
EMS TSFA Trauma System Development Application FY20
EMS Committees - Form
October 11, 2018
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.
School Consent to Enter Student Records into NMSIIS
Immunization - Form
September 17, 2018
This is a customizable form for use by schools to collect consent from parents so students' historic immunization records may be added to NMSIIS.
Breath Alcohol Test Operator Training Request Form
Breath Alcohol - Form
September 14, 2018
Use this form to request test operator training.
Breath Alcohol Key Operator Training Request Form
Breath Alcohol - Form
September 14, 2018
Use this form to request key operator training.
Breath Alcohol Training Cancellation Notification Form
Breath Alcohol - Form
September 14, 2018
Use this form to cancel training requests.
Breath Alcohol Test Operator Online Recertification Training Request Form
Breath Alcohol - Form
September 14, 2018
Use this form to request online test operator recertification.
Breath Alcohol Instrument Peripheral Ordering
Breath Alcohol - Form
September 14, 2018
Breath Alcohol Instrument Peripheral Ordering
Family Planning Sterilization Request Form
Family Planning - Form
August 31, 2018
Use this form to request sterilization.
Family Planning Services Consent Form
Family Planning - Form
August 31, 2018
Use this form to provide consent for family planning services.
Medical Cannabis Program Complaint and/or Injury Report Form
Medical Cannabis Program - Form
August 22, 2018
The Medical Cannabis Program Complaint Form, is utilized to assist in resolution of outstanding issues, regarding, Licensed Non Profit Producers, Dispensaries, Manufacturers and Laboratories.
The Uniform Health Care Decisions Act
Clinical Services - Form
August 20, 2018
General information regarding capacity and the designation of a surrogate healthcare decision maker.
Therapy Services: Documentation Form
Clinical Services - Form
August 10, 2018
Therapy Services: Documentation Form
Family Planning Monthly Report – Fax Transmittal Sheet
Family Planning - Form
August 1, 2018
This is the family planning report for fax transmittal.
Family Planning Monthly Report – Deposit Slip Form
Family Planning - Form
August 1, 2018
This is the family planning report for copies of deposit slip.
Family Planning Monthly Report – Payment Ledger
Family Planning - Form
August 1, 2018
This is the family planning report for payment ledger.
Family Planning Monthly Report – Fee Deposit Register
Family Planning - Form
August 1, 2018
This is the family planning report for fee deposit register.
Family Planning Annual Income Worksheet
Family Planning - Form
August 1, 2018
Use this form to generate an annual income report.