New Mexicare Application Form

New MexiCare Application
New MexiCare Application

This form is for individuals interested in applying for New MexiCare.
Authorized Contact *

First NameLast Name
Relationship to Applicant: *
Phone Number*
Please enter a valid phone number.
Authorized Email*
example@example.com
Applicant (Person Needing Assistance)
Applicant Name*

First NameLast Name
Applicant's Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is the Applicant's mailing Address different from the physical address*

YESNO
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Documents to Upload
Documents that show who you are
A current driver’s license: government issued ID

Documents that show how much money you earn monthly
3 months of bank statements (checking and savings)

Documents needed from caregiver
A current driver’s license: government issued ID; Social Security Card

Documents needed for transportation
Copy of vehicle registration; copy of vehicle insurance
Upload copies of required documents

Cancelof
If you are unable to upload documents a New MexiCare Program Coordinator will obtain copies during the home visit.

To check the status of your application, please contact:

New MexiCare at 1-800-432-2080 option #4 or email: newmexicare@altsd.nm.gov
Today'sDate

MonthDayYear
Date
Where did you hear about us? (select one)

Outreach EventFamily / FriendSocial MediaALTSD WebsiteOther
If other please let us know.
Should be Empty:

	YES	NO	Sometimes
Bathing
Dressing
Eating
Transferring
Mobility
Toileting (getting on the toilet, using the toilet)

New MexiCare Application