Forms
NMSIIS Decline to Participate Form
Immunization - Form
January 4, 2021
This form is used by a patient/parent/legal guardian to decline to participate in the New Mexico Statewide Immunization Information System.
COVID-19 Vaccine Consent Form Spanish
Immunization - Form
December 18, 2020
This form should be used as Consent for COVID-19 Vaccinations
General Clinical Request Form
Scientific Laboratory - Form
December 15, 2020
SLD General Clinical Request Form v. 4.1
VFC COVID-19 Troubleshooting Record Form
Immunization - Form
December 15, 2020
This form should be used to report out of range temperature incidents and submit a troubleshooting record to the vaccines for children program.
Credentialing COVID-19 Providers Form
2019 Novel Coronavirus - Form
December 10, 2020
Credentialing COVID-19 Providers Form
EMS Local Funding Program Application Form FY22
EMS Fund Act - Form
November 6, 2020
EMS Local Funding Program Application Form
EMS Local Funding Program Annual Service Report Form FY22
EMS Fund Act - Form
November 6, 2020
EMS Local Funding Program Annual Service Report Form
New Laboratory Application
Medical Cannabis Producers & Distributors - Form
October 29, 2020
MCP New Laboratory Application.
DDW Case Management Form : HP_10.14.2020
Developmental Disabilities Waiver - Form
October 20, 2020
DDW Case Management:HP_10.14.2020
EMS TSFA Trauma System Development Application FY22
EMS Committees - Form
October 13, 2020
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.
COVID Test Request Form
Scientific Laboratory - Form
October 9, 2020
COVID Test Request Form Prefilled
DDW Case Management: OR Budget Worksheet for Adults Sample (10-23-2020)
Developmental Disabilities Waiver - Form
October 6, 2020
DDW Case Management: OR Budget Worksheet for Adults Sample
PASRR Level 1 Identification Screen Form
Pre-Admission Screening & Resident Review - Form
October 5, 2020
Preadmission Screening and Resident Review Level I Identification Screen
New Mexico Midwifery Student Workbook
Certified Nurse Midwives and Licensed Midwives - Form
September 29, 2020
New Mexico Midwifery Student Workbook
Medical Cannabis Further Guidance Labeling
Medical Cannabis Producers & Distributors - Form
September 29, 2020
Medical Cannabis Further Guidance Labeling
Service Model Selection/ Change Form
Supports Waiver - Form
September 18, 2020
Service Model Selection Change Form
ACQ Application Questionnaire
Advisory Council on Quality - Form
September 11, 2020
ACQ Application Questionnaire (8/2019)
Nursing and Health Initiatives: Decision Consultation Form
Clinical Services - Form
September 2, 2020
Nursing and Health Initiatives: Decision Consultation Form
Medical Cannabis Manufacturer Application
Medical Cannabis Producers & Distributors - Form
August 19, 2020
This is the application for those interested in manufacturing medical cannabis products.