Forms
National Guardianship Association – Bill of Rights-rev-11-4-22
Constituent Support - Form
December 8, 2023
National Guardianship Association – Bill of Rights-rev-11-4-22
NM Uniform Healthcare Decisions Act (UHCDA): Surrogate Decision Maker
Constituent Support - Form
December 8, 2023
NM Uniform Healthcare Decisions Act (UHCDA): Surrogate Decision Maker
New Mexico Medical Orders for Scope of Treatment (MOST) Form
Constituent Support - Form
November 2, 2023
New Mexico Medical Orders for Scope of Treatment (MOST) Form
Midwife Complaint Form
Certified Nurse Midwives and Licensed Midwives - Form
October 30, 2023
Use this form to file a complaint against a midwife.
VFC Northeast Region Temperature Log Form
Immunization - Form
October 23, 2023
Colfax, Guadalupe, Harding, Los Alamos, Mora, Rio Arriba, San Miguel, Santa Fe, Taos, and Union
VFC Southwest Region Temperature Log Form
Immunization - Form
October 23, 2023
Catron, Dona Ana, Grant, Hidalgo, Luna, Otero, Sierra, and Socorro
VFC Routine Vaccine Management Plan
Immunization - Form
October 23, 2023
The New Mexico VFC Program requires each practice to develop and maintain a Routine Vaccine Management Plan. Properly completing this template will meet the VFC Program requirement for VFC Program participants to have written vaccine storage and handling plans.
VFC Emergency Vaccine Management Plan
Immunization - Form
October 23, 2023
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.
EOL1 – Medical Aid in Dying Reporting Form
Vital Records - Form
October 12, 2023
EOL1 – Medical Aid in Dying Reporting Form
Sterilization – Protocol and Review Form
Family Planning - Form
October 3, 2023
Sterilization – Protocol and Review Form
The Uniform Health Care Decisions Act Surrogate Healthcare Decision Form
Clinical Services - Form
August 28, 2023
General information regarding capacity and the designation of a surrogate healthcare decision maker.
Medically Fragile Waiver Registration Form
Medically Fragile Waiver - Form
August 18, 2023
Medically Fragile Waiver Registration Form
NMHSC Stipend Program Guidelines for 2023
Primary Care & Rural Health - Form
August 4, 2023
NMHSC Stipend Program Guidelines for 2023
1915c Waivers Individual Transition Plan Checklist
Developmental Disabilities Waiver - Form
August 3, 2023
1915c Waivers Individual Transition Plan Checklist
NM J-1 Waiver Application 2024
Primary Care & Rural Health - Form
August 2, 2023
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.
EOL1 – Medical Aid in Dying Reporting Form
Vital Records - Form
August 2, 2023
EOL1 – Medical Aid in Dying Reporting Form