PROVIDERS

The Health Care Authority’s mission is: We ensure that New Mexicans attain their highest level of health by providing whole-person, cost-effective, accessible, and high-quality health care and safety-net services.

HCA Forms

Topic	Adobe
MAD 046 Waiver Review Form	PDF Format
MAD 054 Client Information Update	PDF Format
MAD 056 EPSDT Personal Care Service Plan	PDF Format
MAD 100 – Medicaid Application for Assistance	PDF Format
MAD 100 SP – Solicitud Para Asistencia de Medicaid	PDF Format
MAD 295 Medicaid Transportation Verification	PDF Format
MAD 296 Medicaid Transportation Attestation	PDF Format
MAD 302 Eye Services Prior Approval Request-Contact Lenses	PDF Format
MAD 307 Emergency Medical Services for Non-Citizens Denial of Claims	PDF Format
MAD 308 Emergency Medical Services for Non-Citizens Referral for Eligibility Determination	PDF Format
MAD 308 Emergency Medical Services for Non-Citizens Referral for Eligibility Determination – Spanish	PDF Format
MAD 313 Notification of Birth Form	PDF Format
MAD 316 Midwife Affidavit	PDF Format
MAD 317 Supplemental Release and Indemnification Agreement	PDF Format
MAD 318 Midwife Birthing Approval Form Confirmation/Release	PDF Format
MAD 320 Hysterectomy Consent Form	PDF Format
MAD 331 Title XIX Request for Prior Approval Inpatient Rehavilitation Services	PDF Format
MAD 345 Sterilization Consent Form	PDF Format
MAD 378 ICF MR Long Term Care Assessment Abstract	PDF Format
MAD 379 Program of All-Inclusive Care for the Elderly (PACE) Long Term Care Medical Assessment	PDF Format
Instructions in the use of revised MAD-295 – Medicaid Transportation Verification Form & MAD-296 – Medicaid Transportation Form	PDF Format
MAD 394A Hearing Aid Evaluation Information	PDF Format
MAD 635 Drug Autorization Request Form	PDF Format
MAD 872 Community HealthWorkers (CHW) and Community Health Representatives (CHR) Services	PDF Format
MAD 901 NM Qualified Clinical Trial Medicaid Attestation Form	PDF Format
NM Standard Prior Authorization Form	PDF Format
NM Medicaid FFS Payer Sheet	PDF Format
NM Medicaid FFS Payer Sheet – Turquoise Care System	PDF Format