Forms
COVID-19 Vaccine Troubleshooting Report
Immunization - Form
August 24, 2022
COVID-19 Vaccine Troubleshooting Report
NM J-1 Waiver Application 2024
Primary Care & Rural Health - Form
August 17, 2022
The New Mexico J-1 waiver 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.
VFC School Immunization Consent Form
Immunization - Form
August 17, 2022
This is the form to be completed by parents or guardians indicating whether or not a child is to be vaccinated at school.
VFC Vaccine Administration Form (Part B)
Immunization - Form
August 17, 2022
This form allows you to provide immunization information for entry into NMSIIS.
Hepatitis B Immune Globulin (HBIG) Reporting Form
Perinatal Hepatitis B Prevention - Form
August 9, 2022
Please complete this information on every newborn receiving hepatitis B immune globulin (HBIG).
CDC-Revised document as COVID-19 Vaccine Program Provider Agreement
Immunization - Form
May 18, 2022
CDC-Revised document as COVID-19 Vaccine Program Provider Agreement
CDC-Supplemental document as COVID-19 Vaccine Redistribution Agreement
Immunization - Form
May 18, 2022
CDC-Supplemental document as COVID-19 Vaccine Redistribution Agreement
Turquoise Lodge Authorization to Disclose Health Information Form
Turquoise Lodge Hospital - Form
May 18, 2022
This form should be used to authorize the disclosure of health information for patients.
PHD Assignment of Benefits and Consent Form
Family Planning - Form
April 14, 2022
Assignment of Benefits and Consent Form
Birthing Workforce Retention Fund Application Form
Certified Nurse Midwives and Licensed Midwives - Form
February 18, 2022
Use this form to provide birthing workforce retention fund information to the New Mexico Department of Health.
LM Annual Report
Certified Nurse Midwives and Licensed Midwives - Form
February 3, 2022
LM Annual Report
Electronic Certifier Training Request Form
Vital Records - Form
January 21, 2022
Electronic Certifier Training Request Form
OCHW Registration Form - Deadline Feb 4, 2022
Community Health Workers - Form
January 12, 2022
OCHW Registration Form - Deadline Feb 4, 2022
MWP Student/ Instructor Relationship Form
Certified Nurse Midwives and Licensed Midwives - Form
January 11, 2022
MWP Student/ Instructor Relationship Form
Affidavit of Review of a Certified New Mexico Birth Certificate
Vital Records - Form
December 30, 2021
This form is to be used by agencies and organizations to document eligibility. This should not be accepted in place of a birth certificate.
NMSIIS Decision to Remove Record
Immunization - Form
December 30, 2021
This form is used by a patient/parent/legal guardian to remove records from the New Mexico Statewide Immunization Information System.
NMSIIS Decline to Participate Form
Immunization - Form
December 30, 2021
This form is used by a patient/parent/legal guardian to decline to participate in the New Mexico Statewide Immunization Information System.
FY25 Admission Required Information
Veterans' Home - Form
December 27, 2021
FY25 Admission Required Information
Midwife Reporting Form
Children's Medical Services - Form
December 8, 2021
This form is used by midwives to record their audiological results or to refer parents to a doctor who will follow screen and follow the baby. This form is then submitted to the New Mexico Department of Health.
Newborn Hearing Screening Referral Form
Children's Medical Services - Form
December 8, 2021
This form is used to refer parents to a doctor for a newborn hearing screening.