Hemodialysis Technician Program Initial Application

Hemodialysis Technician Program Initial Application
APPLICATION INSTRUCTIONS: The application is not complete until the required documentation has been submitted, and the application fee has been paid. Incomplete applications will not be reviewed and will expire in six months.
1. Complete and submit this online initial program application.
2. Complete the payment form and fax it to (505) 841-8347
3. Contact the nurse surveyor, Patricia Fernandez, Nurse.Surveyor@bon.nm.gov, for directions on how to submit required documents electronically. Documents must be numbered and named according to the checklist. All required documents must be submitted in their entirety. Partial submissions will not be reviewed.
Date of application*

MonthDayYear
Date
Agency Information
Legal name of agency*
Alternate name
Agency Address*

Address

Address Line 2

CityState

Zip Code
Agency phone number*
Please enter a valid phone number.
Owner Name*

First NameLast Name
Owner Address*

Address

Address Line 2

CityState

Zip Code
Administrator name*

First NameLast Name
Administrator phone number*
Please enter a valid phone number.
Administrator email*
example@example.com
Name of proposed nurse educator for whom approval is requested*

First NameLast Name
Proposed nurse educator license number*
Telephone number of proposed Nurse Educator*
Please enter a valid phone number.
Email address of proposed nurse educator*
example@example.com
Name of nursing director*

First NameLast Name
Name of medical director*

First NameLast Name
New Mexico Department of Health license number*
Expiration date of current Department of Health license*

MonthDayYear
Date
CLINICAL PRECEPTORS
Will the program utilize clinical preceptors? If yes, provide name(s) and license number(s) below.*

YesNo
Name & License number*
Name & License number*
Name & License number*
Name & License number*
Name & License number*
Name & License number*
Name & License number*
Submitted by: Name*

First NameLast Name
Position/title*
Email address*
example@example.com
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Hemodialysis Technician Program Initial Application

Agency Information

CLINICAL PRECEPTORS