Forms
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.
Prefilled Specimen Submission Form for norovirus testing (raw stool)
Norovirus - Form
September 9, 2019
Prefilled Specimen Submission Form for norovirus testing (raw stool)
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)
Asthma Action Plan for Schools
Asthma - Form
February 12, 2019
This action plan form was created by the New Mexico Council on Asthma (NMCOA) for school nurses, health care providers and families. It allows for an individual action plan to be developed for each student to ensure proper handling of asthma based on severity.
Community Health Worker State Certification Specialty Track Advanced Application
Community Health Workers - Form
January 30, 2019
This is the Community Health Worker State Certification Specialty Track Advanced Application.
Aplicación para la Certificación Estatal como Especialistas Avanzados
Community Health Workers State Certification Application
Community Health Workers - Form
January 24, 2019
This is the application detailing required documentation, eligibility requirements, and submission guidelines for Community Health Worker state certification.
Aplicación para la Certificación Estatal de los Trabajadores de la Salud Comunitaria
Sample Collection Kit Order Form
Kit Preparation - Form
November 2, 2018
Use this form to order sample collection kits.
Track Your Child's Development - Checklist
Maternal & Child Health Epidemiology - Form
October 26, 2018
This is a checklist that allows you to fill out your child's name, age, and date and then check off the milestones your child has already achieved.
Breath Alcohol Training Cancellation Notification Form
Breath Alcohol - Form
September 14, 2018
Use this form to cancel training requests.
Chemistry Analysis Request Form
Chemistry - Form
July 16, 2018
Use this form to request general chemistry analysis.
CMS Telephone Referral Form
Children's Medical Services - Form
April 5, 2018
CMS Telephone Referral Form
Occupational Health Case Reporting
Occupational Health Surveillance - Form
March 15, 2018
This confidential case reporting form allows health care providers and lab directors to meet the requirements of the law by reporting occupational and/or injuries to the New Mexico Occupational Health Surveillance Program (OHSP) within 24 hours. Additional instructions for reporting a case are contain within the document.