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?*

AdministratorOwner
New administrator name*

First NameLast Name
Title*
Administrator telephone number*
Please enter a valid phone number.
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*

Cancelof
Does the facility intend to maintain the current approved medication aide program including the program curriculum?*

YesNo
Does the facility intend to maintain the current board approved medication aide program nurse educator?*

YesNo
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.
Nurse educator email address*
example@example.com
Has a new administrator been appointed for the facility?*

YesNo
New Administrator Name*

First NameLast Name
New administrator title*
New administrator phone number*
Please enter a valid phone number.
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.
Email address*
example@example.com
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Medication Aide Program Notification of Change of Administrator / Owner