Forms
Supports & Services - Administrator Interview Tool
Regional Office form used by a CM or provider agency to request an exception to the DD Waiver Service Standards that directly impacts a person in service or relates to service and/or agency requirements.
Mi Via Self-Directed Waiver: Service and Support Back-Up Plan Acknowledgement Form
This form should be used to request a card for all new Licensed Nonprofit Producer employees, Board Members, or contract worker or to request a replacement card for one of these staff members. For a new employee card please ensure you submit the items requested on the form.
CMS Telephone Referral Form
All VFC providers are required to submit this annual VFC certification form in order to continue receiving VFC vaccines.
This confidential case reporting form allows health care providers and lab directors to meet the requirements of the law by reporting occupational and/or injuries to the New Mexico Occupational Health Surveillance Program (OHSP) within 24 hours. Additional instructions for reporting a case are contain within the document.
Signing this form is acknowledgement that the HCBS Consumer Rights and Freedoms document has been received, explained and signed.
This form is to be used for needles/syringes, and e-kit medications and is for Vaccines for Children Approved Sites Only.
This is the letter addressed to parents or legal guardians to determine whether or not a child is to be vaccinated at school. This letter is to be sent out with the VFC school immunization consent form.
VFC Middle School Vaccination Letter/Permission Form (Spanish)
Medical Emergency Response Plan Form (side-by-side format)
Medical Emergency Response Plan Form (standard format)
SHM - Chapter 1 - Supervisory School Nurse Performance Evaluation Tool for Medical Supervisors
This document is for providers: guidelines and important dates for the transition to digital data loggers.
SHM - Chapter 2 - Adverse Event Form
SHM - Chapter 3 - Health History Form (Initial)
SHM - Chapter 3 - Hearing Screening Form
SHM - Chapter 3 - Release of Medical Information Form (Parents)
SHM - Chapter 3 - General Referral Form