Medication Aide Initial Program Application

Medication Aide Initial Program Application
APPLICATION INSTRUCTIONS: The required documentation as defined by the CMA Program Initial Application checklist is due at the time of submission. Please have documentation ready before you start this application. The application is not complete until the application fee has been paid. Incomplete applications will not be reviewed and will expire in six months.
1. Applications must be submitted by an agency administrator in accordance with Paragraph (2) of Subsection C of 16.12.5.17 NMAC.
2. Complete and submit this online initial program application.
3. Complete the payment form and fax it to (505) 841-8347.
4. Contact the Nurse Surveyor, Nurse.Surveyor@bon.nm.gov, for directions on how to submit required documents electronically. Documents must be numbered and named according to the checklist.
Date of application*

MonthDayYear
Date
Type of program*
Type of training program*
Agency Information
Legal name of agency*
Alternate name
Agency address*

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Agency telephone number*
Please enter a valid phone number.
Type of agency*

Long term care (LTC)Skilled nursingAssisted LivingICF/IDDDD WaiverEducation only
Agency owner*
Owner mailing address*

Address

Address Line 2

CityState

Postal / Zip Code
Administrator name*

First NameLast Name
Administrator telephone number*
Please enter a valid phone number.
Administrator email address*
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
Has the proposed nurse educator previously attended a BON nurse educator orientation as required by Medication Aide Rules (Subsection B of 16.12.5.12 NMAC)?

NO. Nurse educators who have not already attended the orientation may register on the medication aide program page, https://www.bon.nm.gov/cmap/.YES. Upload certificate or verification of attendance.
Verification of Nurse Educator Orientation Attendance

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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?*

Yes. Please provide name(s) and license number(s) belowNo
Preceptor name & license number
Preceptor name & icense number
Preceptor name & license number
Preceptor name & license number
Preceptor name & license number
Submitted by: Name*

First NameLast Name
Position or title*
Telephone number*
Email address*
example@example.com
Program Description and implementation plan, including timelines*

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Program objectives – Medication aide I and/or II*

Refer to Subsection A of 16.12.5.17 NMAC for specific program objectives content requirements
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Organizational Chart - Refer to Subsection C of 16.12.5.19 NMAC*

A current organizational chart that shows the position of the medication aide program within the overall structure of the agency, clearly indicating the lines of authority and responsibility and channels of communication
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Nurse Educator (NE): Current resume and licensure verification*

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NE verification of BON orientation attendance if requirement currently met

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Clinical preceptor: Current resume and licensure verification*

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Other faculty for classroom instruction: Current resume and licensure verification*

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Program curriculum - Refer to 16.12.5.19 NMAC for specific classroom and clinical curriculum subject area requirements for medication aide I and/or and II*

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Evaluation tools – medication aide I and/or medication aide II student*

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Evaluation tools – CMA I and/or CMA II*

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Job description - CMA I and/or II*

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Policies for the Medication Aide I and/or II student*

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Policies for the CMA I and/or CMA II*

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Continuing education plan*

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List clinical affiliations and upload agreements

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ADMINISTRATOR ACKNOWLEDGEMENT AND ATTESTATION

I affirm the following:
- I have reviewed the medication aide rules, 16.12.5 NMAC;
- There are sufficient resources available to meet the needs and purpose of the program;
- I understand the application is not complete until required documentation has been submitted and the application fee has been paid.
- I understand incomplete applications will not be reviewed and will expire in six months.
By digitally signing below, I attest that all the information provided in this webform is true, accurate, and complete to the best of my knowledge. I understand that any false or misleading information may result in consequences as determined by applicable laws and regulations. I acknowledge that the digital signature is my legally binding electronic signature for this document.
Signature*

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Medication Aide Initial Program Application

Agency Information

CLINICAL PRECEPTORS