Forms
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)
Midwife Complaint Form
Certified Nurse Midwives and Licensed Midwives - Form
August 19, 2025
Use this form to file a complaint against a midwife.
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
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.
New Mexico Child & Adult Tuberculosis (TB) Assessment
Tuberculosis Prevention - Form
July 18, 2025
New Mexico Child & Adult Tuberculosis (TB) Assessment
NMHSC Stipend Application for 2025
Primary Care & Rural Health - Form
June 26, 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.
Inspection of Public Records Request Form
Inspection of Public Records Act - Form
June 26, 2025
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.
VFC Southeast (B) Region Temperature Log Form
Immunization - Form
June 5, 2025
Eddy, Lea, Lincoln, and Roosevelt
VFC Southwest Region Temperature Log Form
Immunization - Form
June 5, 2025
Catron, Dona Ana, Grant, Hidalgo, Luna, Otero, Sierra, and Socorro
Newborn Screening Test Refusal - Form (Spanish)
Children's Medical Services - Form
April 18, 2025
Programa de Detección para Recién Nacidos de Nuevo Mexico
Certificate of Exemption from Immunization (English)
Immunization - Form
April 4, 2025
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.