New Mexi-Care Application
This form is for individuals who reside in the following counties: Catron, De Baca County, Harding, Lincoln, McKinley, Otero, Rio Arriba, San Juan, San Miguel, Santa Fe, Sierra, Taos, or Valencia; and meet the income requirements. To review the details of this program go to www.aging.nm.gov/newmexicare
Requestor
First Name
Last Name
Requestor Phone Number
-
Area Code
Phone Number
Requestor E-mail
example@example.com
Requestor Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Applicant (Person Needing Assistance)
Applicant Name
First Name
Last Name
Applicant's Physical Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Applicant's Date of Birth
-
Month
-
Day
Year
Date
County where applicant resides
Catron
Harding
De Baca
Lincoln
Sierra
San Miguel
Other
Applicant's Phone Number
Please enter a valid phone number.
Applicant's Monthly Net Income
Include all sources of income, social security, retirement, pensions, etc. - [net means after tax amount of all sources]
Source of income (select all that apply)
Social Security
Retirement
Pensions
Other
Level of Care Criteria
Select the best option for each activity for the applicant. An Aging & Long Term Services Department employee will complete an in-home assessment and will provide final determination of eligibility.
Mobility
Can conduct activity without difficulty
Can conduct activity with minimal difficulty
Has difficulty carrying out activity
Unable to carry out the activity
Food preparation and nutrition
Can conduct activity without difficulty
Can conduct activity with minimal difficulty
Has difficulty carrying out activity
Unable to carry out the activity
Personal hygiene
Can conduct activity without difficulty
Can conduct activity with minimal difficulty
Has difficulty carrying out activity
Unable to carry out the activity
Toileting
Can conduct activity without difficulty
Can conduct activity with minimal difficulty
Has difficulty carrying out activity
Unable to carry out the activity
Medications
Can conduct activity without difficulty
Can conduct activity with minimal difficulty
Has difficulty carrying out activity
Unable to carry out the activity
Light house keeping
Can conduct activity without difficulty
Can conduct activity with minimal difficulty
Has difficulty carrying out activity
Unable to carry out the activity
Does the applicant need transportation to and from health appointments, stores, or community events?
Yes
No
Unsure
Number of adult protective service investigations within the last 24 months (documentation may be requested during in-home assessment)
0
1-2
3 or more
Unknown
Number of hospitalizations in the 12 months
0
1-2
3 or more
Number of visits to the emergency room in the last 12 months
0
1-2
3 or more
Do any of the following pertain to the Applicant?
Applicant is raising a grandchild (grandchild is under the age of 18 lives with applicant and is reliant on applicant for care)
Applicant cares for an adult who has an intellectual or developmental disability
Applicant is homebound
Applicant is bedbound
Please identify all medical diagnoses for the applicant, if none, indicate N/A
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Caregiver Information
Name and addresses of caregivers currently providing support for the applicant
At what frequency does the applicant need support with the following?
Homecare
Please Select
Daily
Weekly
Monthly
Personal Care
Please Select
Daily
Weekly
Monthly
Transportation
Please Select
Daily
Weekly
Monthly
How many hours per week for each activity does the applicant receive help from the caregiver?
Homecare
Please Select
1-5
5-10
11-15
20+
Personal
Please Select
1-5
5-10
11-15
20+
Transportation
Please Select
1-5
5-10
11-15
20+
Mode of transportation for each caregiver
Car
Bus
Uber/Rideshare
Other
If applicant requires transportation services, are caregiver's vehicles registered and insured
Yes
No
Unknown
Will caregiver(s) be available to attend online or in person trainings (CPR/First Aid, Safe Transfer procedures, etc)
Yes
No
What support/training would the caregiver(s) like to receive?
Have any of the caregivers had a substantiated investigation of abuse, neglect, or exploitation with Adult Protective Services?
Yes
No
Unknown
If yes, please provide approximate year of occurrence and details of the substantiated allegations (do not include name of victim)
Upload Copies of Income
Social security award letters, bank statements (3 months total) or other supporting documentation.
Upload copies of income
Browse Files
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If you are unable to upload you can mail to - 8500 Menaul Blvd NE Suite B-350 Albuquerque, NM 87112. Or fax to 1-855-414-4885. Please note, the application is not complete and will not be reviewed until all paperwork has been submitted, if you have any questions about your application and need to speak with someone from the New Mexi-Care program, you can call 1-866-654-3219
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