Medication Aide Program Notification of Change of Administrator/Owner

Medication Aide Program Notification of Change of Administrator / Owner
Agency name
What kind of change would you like to report?
New administrator name

First NameLast Name
Title
Administrator telephone number
Please enter a valid phone number.Format: (000) 000-0000.
Administrator email
example@example.com
Appointment date

MonthDayYear
Date
Previous name of facility
Previous owner of facility
Current name of facility
Current owner of facility
Owner's mailing address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Effective date of change of ownership

MonthDayYear
Date
Upload an updated organizational chart that includes and identifies the current facility and medication aide program.

Cancelof
Upload the New Mexico Department of Health operator's license that identiies the facility

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Does the facility intend to maintain the current approved medication aide program including the program curriculum?
Does the facility intend to maintain the current board approved medication aide program nurse educator?
To request approval of a medication aide program nurse educator, submit the online form Medication Aide Program Nurse Educator Request.
Nurse Educator Name

First NameLast Name
Nurse Educator Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Nurse educator email address
example@example.com
Has a new administrator been appointed for the facility?
New Administrator Name

First NameLast Name
New administrator title
New administrator phone number
Please enter a valid phone number.Format: (000) 000-0000.
New administrator email
example@example.com
New administrator appointment date

MonthDayYear
Date
Submitted by

First NameLast Name
Title / Position
Telephone number
Please enter a valid phone number.Format: (000) 000-0000.
Email address
example@example.com
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Medication Aide Program Notification of Change of Administrator / Owner