Forms

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.

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.

Lista de Verificación de Screening Auditivo Neonatal

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.

Audiencia Newborn Screening Familia Hoja de Ruta

Birth Record Search Application Vital Records - Form September 28, 2012

Use this form to request a birth certificate.

Solicitud de Acta de Nacimiento

Death Record Search Application Vital Records - Form September 28, 2012

Use this form to request a death certificate.

Solicitud de Acta de Defunción

Putative Father Registry Search Inquiry Vital Records - Form July 2, 2012

A request for a search of the registry may only be made by a court of competent jurisdiction; a department authorized by law to take actions affecting a child’s health, safety or welfare; the petitioner’s attorney or the mother of the child.

Food Analysis Request Form Biology - Form February 22, 2012

Use this form to request food analysis.

Electronic Transfer of Biology Data Release Form Biology - Form February 22, 2012

Use this form to request the release of confidential patient information data.

Report of Adoption Vital Records - Form February 17, 2012

This form is required for each adoption decreed in the state of New Mexico.

Rabies Submission Form for Veterinarians Zoonotic Diseases - Form June 20, 2011

Veterinarians should use this form to submit specimens to the State Laboratory Division for testing.