APPLY FOR BENEFITS

Kevin S. Settlement
Keep Your Benefits NM
new mexico human services department logo

ABUSE, NEGLECT AND EXPLOITATION OR REPORT OF DEATH FORM

Always notify DHI/IMB immediately after the incident (once you’ve ensured the health and safety of the individual) concerning incidents for individuals receiving the Developmental Disabilities Waiver (DDW), DD Mi Via Waiver, Medically Fragile Waiver or State General Funds contact IMB at 1-800-445-6242.

To notify Child Protective Services of an incident involving a child, call: 1-800-797-3260
To notify Adult Protective Services of a non-DD waiver adult call 1-866-654-3219

IMB ANE Reporting Form

SECTION 1 - INDIVIDUAL'S INFORMATION

Name:(Required)
Gender:(Required)
MM slash DD slash YYYY
Address:(Required)

SECTION 2 - DESCRIPTION OF INCIDENT

Report of Death:
Type of alleged incident:(Required)
MM slash DD slash YYYY
Time of Incident:(Required)
:
Were other individuals present?(Required)

Other People?

PLEASE DESCRIBE WHAT HAPPENED. BE SPECIFIC ABOUT WHO WAS THERE (by name) AND WHAT YOU SAW AND HEARD.

SECTION 3 - ADDITIONAL INFORMATION

Reporter Information

Name

SECTION 4 - AGENCY INFORMATION

SECTION 5 - ADMINISTRATIVE INFORMATION

Check the applicable boxes:(Required)
DD PROGRAMS ONLY - Type of services received by the Individual(Required)
Was an Immediate Action and Safety Plan created?(Required)
Drop files here or
Max. file size: 512 MB.

    SECTION 6 - NOTIFICATION TO AGENCIES REQUIRED

    Legal Guardian:(Required)
    Guardian name:
    Enter guardian phone
    MM slash DD slash YYYY
    Time:
    :
    Address
    Case Manager:(Required)
    Case Manager name:
    Enter agency name
    Enter Case Manager phone
    MM slash DD slash YYYY
    Time:
    :
    Address
    Consultant:(Required)
    Name:
    Consultant's phone number
    Consultant's title (if known)
    MM slash DD slash YYYY
    Time:
    :
    Address

    Outside Agency Referrals

    Law Enforcement:

    Please fill in as much information as you have available regarding what law enforcement agency was contacted.

    Medical Attention/Treatment:

    Please fill in as much information as you have available regarding what medical treatment was sought.

    SECTION 7 - DIGITAL SIGNATURE

    Person submitting this form's information
    Name(Required)
    Please enter today's date.
    MM slash DD slash YYYY