NMDN Eligibility Application for Reimbursement Program

NMDN Eligibility Application for Reimbursement Program

Please complete this application to be considered for eligibility in the NMDN Reimbursement Program.
All reimbursement is subject to funds availability on a first-come, first-served based on receipt date of completed Reimbursement Request Form.
Section 1: Applicant Information

All fields are required unless otherwise noted.
Full Name

First NameLast Name
Preferred Name (if different)

First NameLast Name
Preferred Pronouns
Organization or Affiliation
If Applicable
Email
example@example.com
Phone Number
Please enter a valid phone number.
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Section 2: Qualifications
Please attach one of the following with your application:

Proof of relevant training, certification or licensureTwo letters of reference verifying your experience and service integrity
File Upload*

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Attestation and Indemnification Statement - By checking each box below you are attesting that you have read, understood and agree to each item. All boxes must be checked to qualify for reimbursement.*

I currently carry liability insurance that covers the services I provide.I understand that NMDN is not responsible for the outcome or delivery of my services.I agree to take full responsibility for the work I perform and services I provide.I release and agree to hold harmless the New Mexico Deathcare Network (NMDN), its board, and affiliates from any legal claims, damages, or liabilities that may arise in connection with my services.
Section 3: Declaration

I affirm that the information provided in this application is true and accurate to the best of my knowledge. I understand that submitting false information may disqualify me from the NMDN Reimbursement Program.
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Please allow up to 30 days for application processing and approval by the NMDN Reimbursement Committee.

All reimbursement is subject to funds availability. Please check with NMDN prior to providing pro bono services for which you plan to seek reimbursement.

Disclaimer:

NMDN provides limited reimbursement for qualifying services but does not supervise, direct, or endorse any providers. All practitioners are independent and solely responsible for the services they provide.

Dispute Resolution Policy for NMDN Reimbursement Program

This policy outlines the process for resolving disputes related to reimbursement decisions, eligibility determination, or interpretations of policies within the New Mexico Deathcare Network (NMDN) Reimbursement Program. The goal to promote a fair, transparent, and respectful resolution process.

1.    Internal Review:

Providers must submit a written request for reconsideration to the NMDN Board within 15 (fifteen) business days of receiving a notice of a disputed decision. The Board will review the request and issue a written response within 30 (thirty) days.

2.    Mediation:

If the dispute is not resolved through internal review, both parties agree to participate in good-faith mediation. Mediation will be conducted by a mutually agreed-upon neutral third party located in New Mexico. Each party is responsible for their own costs associated with mediation.

3.   Arbitration:

If mediation does not result in a resolution, the parties may proceed to binding arbitration. Arbitration will be administered by the American Arbitration Association (AAA) or another mutually agreed upon provider. The arbitration will be held in Albuquerque, NM, and any judgment may be entered in a court of competent jurisdiction. The decision of the arbitrator will be final and binding.

4.    Waiver of Litigation:

By participating in the NMDN Reimbursement Program, providers agree to waive the right to pursue litigation in court, except for enforcing an arbitration award.
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NMDN Eligibility Application for Reimbursement Program

Section 1: Applicant Information

Section 2: Qualifications

Section 3: Declaration