Forms
Primary Care Capital Fund Application
Primary Care & Rural Health - Form
May 13, 2014
Primary and capital fund application for financial assistance to the New Mexico Department of Health and New Mexico finance authority.
EMS Do Not Resuscitate Order Form
EMS Advance Directives - Form
April 30, 2014
This form is to place a formal Do Not Resuscitate order. For covered persons in cardiac or respiratory arrest, resuscitative measures to be withheld include external chest compressions, intubation, defibrillation, administration of cardiac medications and artificial respiration.
Pesticide Illness Reporting
Occupational Health Surveillance - Form
April 2, 2014
This form should be used by all healthcare professionals to report pesticide related illness and injury of workers in New Mexico to the Occupational Health Surveillance Program. It includes a list of questions you can ask your patients and the symptoms of pesticide exposure are also listed in both English and Spanish.
Air Quality Analysis Request Form
Air and Heavy Metals - Form
March 18, 2014
Use this form to request air quality analysis.
Acknowledgment of Paternity Statement
Vital Records - Form
February 28, 2014
Establishment of paternity means the establishment of the parent-child relationship. This Acknowledgment of Paternity (AOP) shall be signed under penalty of perjury by the mother and by the man seeking to establish paternity.
EMS Trauma Registry Username & Password Request Form
EMS Trauma Care Program - Form
February 25, 2014
This form should be used to request a username and password for the emergency medical services trauma registry.
Fort Bayard Financial Disclosure Form
Fort Bayard Medical Center - Form
December 19, 2013
This financial disclosure form is required for admission to Fort Bayard Medical Center.
Fort Bayard Financial & Payment Contract Form
Fort Bayard Medical Center - Form
December 19, 2013
This financial payment contract form is required for admission to Fort Bayard Medical Center.
Fort Bayard Patient Demographics Form
Fort Bayard Medical Center - Form
December 19, 2013
This patient demographics form is required for admission to Fort Bayard Medical Center.
EMS RETRACS TPIC Performance Improvement Reporting Form
EMS Committees - Form
November 27, 2013
This form should be used to report performance improvement issues.
EMS Medical Orders for Scope of Treatment Form
EMS Advance Directives - Form
November 21, 2013
This form should be used by a physician to outline a plan of care respecting the patient’s wishes concerning care at life’s end.
HIV/AIDS Confidential Case Reporting Form
HIV Surveillance & Epidemiology - Form
October 17, 2013
Use this form to confidentially report a case of HIV/AIDS.
Audiology Survey from Subcommittee
Children's Medical Services - Form
September 30, 2013
This survey form helps the New Mexico Early Detection and Intervention advisory council gather current data in order to update the resource list of professionals who provide newborn and pediatric audiology services in our state.
Physician Reporting Form
Children's Medical Services - Form
August 13, 2013
This form is used by physicians to report the results of their hearing screen or diagnostic audiological evaluation to the New Mexico Department of Health.
EMS Parental Consent for EMSFR or EMT-B Licensure Form
Emergency Medical Systems - Form
June 12, 2013
This form should be used by the parents of children applying for EMSFR or EMT-B licensure.
Putative Father Registry Inclusion Request
Vital Records - Form
April 8, 2013
This is a request for inclusion the New Mexico Putative Father Registry. This request is made either voluntarily by a father who hereby gives notice that he intends to claim paternity or has claimed paternity of his child, or involuntarily on the basis of a court order determining paternity.
Medical Cannabis HIPAA Authorization
Medical Cannabis Resources, Publications and Archives - Form
March 22, 2013
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.
Newborn Hearing Screening Checklist
Children's Medical Services - Form
February 18, 2013
This form helps you track your baby’s hearing, understanding and talking in their first year.
Family Roadmap
Children's Medical Services - Form
December 19, 2012
This form makes it easy for families to track their baby’s hearing screening follow-up tasks from birth to 6 months old.