Forms

NMHSC Stipend Application for 2024 - 2025 Primary Care & Rural Health - Form July 9, 2024

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.

NMSIIS User Security and Confidentiality Agreement 2025 Immunization - Form May 22, 2024

NMSIIS User Security and Confidentiality Agreement 2024

NMSIIS Organization Security and Confidentiality Agreement 2025 Immunization - Form May 22, 2024

Participant organization security and confidentiality agreement for the New Mexico Statewide Immunization Information System.

SLD 2025 IR (Infrared) 9000 Training Schedule Breath Alcohol - Form April 11, 2024

Use this form to request online training.

Substitute W-9 Breast and Cervical Cancer - Form February 2, 2024

BCC Program New Provider Application Documents - Substitute W-9

Campaign Contribution Disclosure Form Breast and Cervical Cancer - Form February 2, 2024

BCC Program New Provider Application Documents - Campaign Contribution Disclosure Form

Hepatitis B Pregnancy Reporting Form Infectious Disease Epidemiology - Form January 8, 2024

This form is used to report Hepatitis Pregnancy

NMDOH OTC Standing Orders Prescription Template OTC Standing Orders - Form December 13, 2023

NMDOH OTC Standing Orders Prescription Template

VFC TSR Form Vaccines for Children - Form October 23, 2023

VFC TSR Form

EOL1 – Medical Aid in Dying Reporting Form Vital Records - Form October 12, 2023

EOL1 – Medical Aid in Dying Reporting Form

Pharmacist Telehealth Consent Form Family Planning - Form October 5, 2023

Pharmacist Telehealth Consent Form

Pharmacist Telehealth Consent Form
Pharmacist Telehealth Consent Form - Spanish

Birth Control Pills – How to Start Taking Birth Control Pills Family Planning - Form September 29, 2023

Birth Control Pills – How to Start Taking Birth Control Pills

Sterilization – Protocol and Review Form Family Planning - Form September 29, 2023

Sterilization – Protocol and Review Form

Adult TSR Form Immunization - Form August 11, 2023

Adult TSR Form

NMHSC Stipend Program Guidelines for 2023 Primary Care & Rural Health - Form August 4, 2023

NMHSC Stipend Program Guidelines for 2023

EOL1 – Medical Aid in Dying Reporting Form Vital Records - Form August 2, 2023

EOL1 – Medical Aid in Dying Reporting Form

NMHSC Stipend Application for 2023 Primary Care & Rural Health - Form July 12, 2023

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.