Forms

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.

This form allows an adult to request a gender designation change on their own birth certificate.

This form allows the legal parent/guardian to request a gender designation change on their child's birth certificate.

This form allows parents to request a gender designation change on their child's birth certificate.

This additional form is required to request a gender change on a birth certificate if the registrant is 40 years of age or over.

This authorization allows the Department of Health (DOH) to disclose confidential health information about you. The authorization may be revoked. It will remain in effect for six (6) months unless a different time is stated. You are entitled to a copy of the completed authorization. There may be fees charged for any copying associated with this request. If you are a person with a disability and you require this authorization in an alternative format or require a special accommodation to complete this form, you may request assistance from staff at any DOH location or from the DOH Chief Privacy Officer.

Authorization to Disclose Health Information (Spanish)

CNA Reciprocity Form

All STD cases diagnosed or treated in New Mexico are required by law to be reported to the STD Program in Santa Fe. Additionally, any medical laboratory anywhere in the United States performing testing for New Mexico must report positive results to the New Mexico STD Program in Santa Fe.

Therapy Services: Discontinuation of Therapy Report (Template)

Prefilled Specimen Submission Form for norovirus testing (raw stool)

Prefilled Specimen Submission Form for enteric bacteria testing (transport media)

ACQ Authorization Form for Appointments

This is the fillable form reference tool for THERAP.

Fill out this application to apply for admission to the New Mexico State Veterans' Home.

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.

Attachment A
Attachment C

FIT Developmental Specialist Recertification Application

FIT Developmental Specialist Initial Certification Application

Access to public records is one of the fundamental rights afforded people in a democracy. Even where there is no statute, a common law right to inspect and copy public records affords members of the public the opportunity to keep a watchful eye on government. In accordance with the Inspection of Public Records Act by the New Mexico Attorney General, you may use this form to submit a formal request to inspect public records.

This form should be completed to determine financial eligibility for adult patients.

Radio Frequency Interference Check - Intoxilyzer 8000