Forms and Tools

Complaints/Report Incidents Forms and Guides

Incident Managment

• (IMB) System Guide 2010
• (IMB) Online Incident Report Form with Instructions (SFY 2011) Community Based
• (IMB) Incident Management Report (SFY 2010)
• (IMB) Incident Management - Phone & Fax Reference Cards (SFY 2010)
• (IMB) Incident Management - Posters with Phone & Fax (SFY 2010)
• (IMB) Incident Management Provider Training Powerpoint (SFY 2011)
• (IMB) Provider Training Correspondence (SYF 2012)
• (IMB) Provider Training Signed Letter (SYF2011)



Health Facility Licensing & Certification

• (HFL&C) Online Incident Report Form (SFY 2011)
• (HFL&C) Licensing & Certification's Incident Report (SFY 2011)
• HFL & C Incident Reporting Card
• (HFL&C) Licensing & Certification's Incident Management Guide (SFY 2010)
• (HFL&C) Provider Training PowerPoint
• (HFL&C) Licensing & Certification's IMS Poster
• (HFL&C) Licensing & Certification's NEW FEE SCHEDULE (2.07)
• Tribal Phone Numbers

Caregivers Criminal History Screening Forms

To Order Forms for Criminal Screening
Please Call (505) 476-0801

• Authorization for Release of Information
• Affidavit - No Known Criminal History
• New Care Provider/Facility Information Form
• FBI Applicant Fingerprint Card Order Form
• (CCHSP) Link to Consolidated Online Registry (COR) (12.06)
• (CCHSP) Consolidated Online Registry Access (COR) Form (11.06)
• (CCHSP) Respite Collaborative (10.23.06)
• Notice of Caregiver Resignation/Termination
• Administrative Reconsideration Request Form

Risk Assessment Inventory Forms

• Depression
• Falls
• Osteoporosis
• Physical & Nutritional Management
• Skin Breakdown
• Substance Abuse

New Mexico Division of Health Improvement

To Make a Complaint by Phone,
Call the Department of Health's Incident Management Bureau at 1(800) 445-6242
or
The Health Facility Licensing & Certification Bureau at 1 (800) 752-8649