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New Mexico Form Center -

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Form

Description

e1.pdf Employer's First Report of Injury
noa.pdf Notice of Accident or Occupational Disease Disablement -English and Spanish
e10-1.pdf Inpatient Data UB-92 Supplement
e9.pdf Inpatient Medical Data Provider Profile
e6.pdf Notice of Benefit Payment (Subsequent Report)
complaint.pdf Workers Compensation Complaint form
summonsjudge.pdf Summons for Application to Workers' Compensation Judge
hipaa.pdf HIPAA Form
hipaa-sp.pdf HIPAA Form (Spanish)
response.pdf Response to Worker's Complaint
workers_response.pdf Workers Response to Complaint
wcjudge.pdf Application to Workers' Compensation Judge
setting.pdf Request for Setting
hcp-state.pdf Motion for approval of out of state health care provider
disqualify.pdf Disqualification of W.C. Judge
hcp-letter.pdf Form Letter to Health Care Provider
ls_petition.pdf Petition for Lump Sum Payment
lss_rtw.pdf Petition For Lump Sum Payment Return to Work
readme.pdf Instructions for filing Complaints, Application to WCJ, Lump Sum, HCP, & check lists for the above
lss_debt.pdf Petition For Partial Lump Sum Payment For Debts
summons.pdf Summons for Workers' Compensation Complaint
accept_reject.pdf Notice of Acceptance or Rejection of Recommended Resolution
subpoena.pdf Subpoena or Subpoena Duces Tecum
hcp-change.pdf Notice of Change of Health Care Provider
hcprequest.pdf Request for Change of Health Care Providers
hcp-object.pdf Objection to Notice of Change of Health Care Provider
e7.pdf Trading Partner Profile
sole.pdf Sole Proprietor Affirmative Election Form
e8.pdf Proof of Coverage Profile
cba1.pdf Affirmative Election
cba2.pdf Election to Accept
cba3.pdf Revocation
cba4.pdf Limited Liability Company Member Affirmative Election
cba5.pdf Executive Employee Affirmation Election
elect_refuse.pdf Election To Refuse
expedited_hearing.pdf Joint Request for Expedited Section 52-1-12D Hearing
recomforms.pdf Waiver Forms
application.pdf Application For Individual Self-Insurance
board_resolution.pdf Resolution Of Board Of Directors
endorsement_ind.pdf New Mexico Amendatory Endorsement (Individual)
endorsement_group.pdf New Mexico Amendatory Endorsement (Group)
letter_credit_ind.pdf Irrevocable Standby Letter Of Credit (Individual)
letter_credit_group.pdf Irrevocable Standby Letter Of Credit (Group)
bond_ind.pdf Surety Bond (Individual)
bond_group.pdf Surety Bond (Group)
parental_guaranty.pdf Parental Guaranty
fraud_poster.pdf POSTER - Fraud Poster
poster8x11.pdf POSTER - "If You Are Injured At Work" (8 x 11) (2 part - to be put together to make 11 x 17)
poster11x17.pdf POSTER - "If You Are Injured At Work" (11 x 17)
SAW-RTWflyer.pdf POSTER - Stay at Work / Return to Work
empguide.pdf BROCHURE - A Guidebook for Employers in New Mexico
injured_workers_workbook.pdf BROCHURE - Workbook for Injured Workers in New Mexico