Forms
Certificate of Exemption from Immunization (English)
Immunization - Form
January 26, 2026
This form may be used by individuals requesting a religious or medical exemption to immunization for their children whom attend any public, private or parochial pre-school, kindergarten, elementary, secondary school, or home school and for children attending daycare of childcare facilities.
Certificate of Exemption from Immunization (Spanish)
Immunization - Form
January 20, 2026
This form may be used by individuals requesting a religious or medical exemption to immunization for their children whom attend any public, private or parochial pre-school, kindergarten, elementary, secondary school, or home school and for children attending daycare of childcare facilities.
Radio Frequency Interference Check - Intoxilyzer 9000
Breath Alcohol - Form
December 10, 2025
Radio Frequency Interference Check - Intoxilyzer 9000
NMDOH Certified Doula Manual Application
Maternal Health - Form
October 20, 2025
Manual application for the NMDOH Doula certification.
Referring to UNM for Breast or Cervical Services
Breast and Cervical Cancer - Form
August 27, 2025
Referring to UNM for Breast or Cervical Services
National Breast Cancer Foundation Grant Referral
Breast and Cervical Cancer - Form
August 27, 2025
National Breast Cancer Foundation Grant Referral
New Provider Application
Breast and Cervical Cancer - Form
August 26, 2025
BCC Program New Provider Application Documents - New Provider Application
Provider Contact Form
Breast and Cervical Cancer - Form
August 26, 2025
BCC Program New Provider Application Documents - Provider Contact Form
Provider Credential List
Breast and Cervical Cancer - Form
August 26, 2025
BCC Program New Provider Application Documents - Provider Credential List
FY26 Eligibility and Consent Form (English)
Breast and Cervical Cancer - Form
August 26, 2025
FY26 Eligibility and Consent Form (English)
FY26 Eligibility and Consent Form (Spanish)
FY26 Screening and Referral Form
FY26 Clinic Based Patient Navigation Form
Breast and Cervical Cancer - Form
August 26, 2025
FY26 Clinic Based Patient Navigation Form (Print Version)
FY26 Clinic Based Patient Navigation Form (PDF Fillable Version)
VFC Vaccine Administration Form (Part B)
Immunization - Form
August 13, 2025
This form allows you to provide immunization information for entry into NMSIIS.
Substitute W-9
Breast and Cervical Cancer - Form
August 4, 2025
BCC Program New Provider Application Documents - Substitute W-9
NMHSC Stipend Application for 2027
Primary Care & Rural Health - Form
July 29, 2025
The New Mexico Health Service Corps provides stipends to eligible health professionals during their last two years of training or residency who, in turn, enter into contract with the Department of Health to provide (when licensed) health service for a minimum of two years (1600 hours per year) in an underserved area of New Mexico. This document is the application for this program.
NM J-1 Waiver Application 2026
Primary Care & Rural Health - Form
July 18, 2025
The New Mexico J-1 Waiver Program (State 30 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.