Forms
COVID-19 In-Person Visitation Application
Health Improvement - Form
March 7, 2022
COVID-19 In-Person Visitation Application
COVID-19 In-Person Visitation Application Template
COVID-19 In-Person Visitation Application FAQ
Birthing Workforce Retention Fund Application Form
Certified Nurse Midwives and Licensed Midwives - Form
February 18, 2022
Use this form to provide birthing workforce retention fund information to the New Mexico Department of Health.
LM Annual Report
Certified Nurse Midwives and Licensed Midwives - Form
February 3, 2022
LM Annual Report
Electronic Certifier Training Request Form
Vital Records - Form
January 21, 2022
Electronic Certifier Training Request Form
Compliant Reporting Poster 2022
Health Improvement - Form
January 13, 2022
Compliant Reporting Poster 2022
OCHW Registration Form - Deadline Feb 4, 2022
Community Health Workers - Form
January 12, 2022
OCHW Registration Form - Deadline Feb 4, 2022
MWP Student/ Instructor Relationship Form
Certified Nurse Midwives and Licensed Midwives - Form
January 11, 2022
MWP Student/ Instructor Relationship Form
Affidavit of Review of a Certified New Mexico Birth Certificate
Vital Records - Form
December 30, 2021
This form is to be used by agencies and organizations to document eligibility. This should not be accepted in place of a birth certificate.
NMSIIS Decision to Remove Record
Immunization - Form
December 30, 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
December 30, 2021
This form is used by a patient/parent/legal guardian to decline to participate in the New Mexico Statewide Immunization Information System.
FY25 Admission Required Information
Veterans' Home - Form
December 27, 2021
FY25 Admission Required Information
Midwife Reporting Form
Children's Medical Services - Form
December 8, 2021
This form is used by midwives to record their audiological results or to refer parents to a doctor who will follow screen and follow the baby. This form is then submitted to the New Mexico Department of Health.
Newborn Hearing Screening Referral Form
Children's Medical Services - Form
December 8, 2021
This form is used to refer parents to a doctor for a newborn hearing screening.
New Mexico Midwifery Student Workbook 2022
Certified Nurse Midwives and Licensed Midwives - Form
November 18, 2021
New Mexico Midwifery Student Workbook 2022
Adult Vaccine Consent Form
Immunization - Form
October 1, 2021
This form may be used by adult patients aged 19 and older to provide vaccination consent to a healthcare provider.
Birth Control Pills COCs – Missed Pill Instructions
Family Planning - Form
September 27, 2021
Birth Control Pills COCs – Missed Pill Instructions
Birth Control Pills POPs – Counseling Handout
Family Planning - Form
September 27, 2021
Birth Control Pills POPs – Counseling Handout
Birth Control Pills POPs – Missed Pill Instructions
Family Planning - Form
September 27, 2021
Birth Control Pills POPs – Missed Pill Instructions
Vaginal Contraceptive Ring – Counseling Handout
Family Planning - Form
September 27, 2021
Vaginal Contraceptive Ring – Counseling Handout