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Forms


Photo of the publication cover. Request to Change Gender Designation on a Birth Certificate: 14 Years of Age or Over Consent Form Vital Records - Form October 28, 2019

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



Photo of the publication cover. VFC Troubleshooting Record Form Immunization - Form October 19, 2019

This form should be used to report out of range temperature incidents and submit a troubleshooting record to the vaccines for children program.



Photo of the publication cover. Family Planning Paragard Intrauterine Device Consent Form Family Planning - Form October 15, 2019

Use this form to provide consent for paragard intrauterine device.

Consentimiento de Paragard Dispositivo Intrauterino



Photo of the publication cover. Family Planning Contraceptive Implant Consent Form Family Planning - Form October 15, 2019

Use this form to provide consent for implanon nexplanon.

Consentimiento de Implante Anticonceptivo



Photo of the publication cover. Authorization to Disclose Health Information (English) Security Office - Form October 8, 2019

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)



Photo of the publication cover. New Mexico Nurse Aide Training and Registry Reciprocity Form Program Operations - Form September 26, 2019

New Mexico Nurse Aide Training and Registry Reciprocity Form



Photo of the publication cover. STD Case Reporting Form Sexually Transmitted Diseases - Form September 25, 2019

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.



Photo of the publication cover. Therapy Services: Discontinuation of Therapy Report (Template) Clinical Services - Form September 17, 2019

Therapy Services: Discontinuation of Therapy Report (Template)



Photo of the publication cover. Adult Vaccine Consent Form Immunization - Form September 9, 2019

This form may be used by adult patients aged 19 and older to provide vaccination consent to a healthcare provider.

Adultos Vacuna Formulario de Consentimiento



Photo of the publication cover. VFC Vaccine Administration Form (Part B) Immunization - Form September 9, 2019

This form allows you to provide immunization information for entry into NMSIIS.

VFC Vacuna Forma Administración (Parte B)



Photo of the publication cover. Prefilled Specimen Submission Form for norovirus testing (raw stool) Norovirus - Form September 9, 2019

Prefilled Specimen Submission Form for norovirus testing (raw stool)



Photo of the publication cover. Prefilled Specimen Submission Form for enteric bacteria testing (transport media) Norovirus - Form September 9, 2019

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



Photo of the publication cover. VFC School Immunization Consent Form Immunization - Form August 29, 2019

This is the form to be completed by parents or guardians indicating whether or not a child is to be vaccinated at school.

VFC School Immunization Consent Form (Spanish)



Photo of the publication cover. ACQ Authorization Form for Appointment Advisory Council on Quality - Form August 8, 2019

ACQ Authorization Form for Appointments



Photo of the publication cover. ACQ Application Questionnaire Advisory Council on Quality - Form August 8, 2019

ACQ Application Questionnaire (8/2019)



Photo of the publication cover. Hepatitis B Immune Globulin (HBIG) Reporting Form Perinatal Hepatitis B Prevention - Form August 5, 2019

Please complete this information on every newborn receiving hepatitis B immune globulin (HBIG).



Photo of the publication cover. DDW/MFW/SW Renewing Provider Application Forms DD & Medically Fragile Waiver Provider Enrollment - Form August 2, 2019

DDW/MFW/SW Renewing Provider Application Forms





Photo of the publication cover. DDW Case Management Monthly Site Visit Form Developmental Disabilities Waiver - Form June 27, 2019

This is the fillable form reference tool for THERAP.



Photo of the publication cover. Admission Application for New Mexico State Veterans' Home Veterans' Home - Form June 26, 2019

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

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