On December 4 Governor Michelle Lujan Grisham issued Executive Order 2020-083 which introduced the concept of COVID-Credentialed Practitioners as part of the state’s effort to combat the relentless spread of the COVID -19 virus and the accompanying threat to the New Mexico healthcare delivery system. That document defined two practitioner groups COVID-19 Credentialed Physicians and COVID-19 Credentialed Advanced Practice Clinicians who after being designated by the Secretary of Health shall be considered public employees for the purposes of the Tort Claims Act. The Order also directed the Secretary of Health to develop a process by which these COVID-19 Credentialed Providers shall be identified and appointed.

The Public Health Order of December 9, 2020 issued by Acting Secretary Billy Jimenez provided additional detail to those definitions. The COVID-19 Credentialed Providers “…shall only be considered public employees for purposes of the Tort Claims Act to the limited extent and in the limited circumstances in which such Credentialed Providers provide medical care outside of their normal and privileged scope of practice in a hospital acute care setting to a person infected with the COVID-19 virus or to a person reasonably believed to be infected with the COVID-19 virus.” The December 9th Public Health Order also introduced the process by which qualified physicians and advanced practiced clinicians could apply for the designation of COVID-19 Credentialed Providers. That application form is attached, and this document serves as a guide for completion of that application process.

The December 9th PHO identifies the key determinants of whether the Secretary shall grant that designation as 1.) the applicant’s primary scope of practice, 2.) the nature of the proposed COVID-19 scope of practice, and 3.) the extent of deviation between the two. Thus, applicants should provide as much detail as possible about their current practices and the anticipated services to be provided. A listing of unique training, background, experiences, and/or procedural skills of the applicant will help clarify the value to be delivered. It will also be helpful for the applicant to estimate the available time that might be dedicated to the COVID-19 Credentialing practice.

Because one of the main purposes of the COVID Credentialing is to strengthen the ability of the health system to respond to the pandemic crisis, the application process requires proof of the alignment or agreement between the applicant’s anticipated clinical services and the needs of the facility in which the proposed clinical services shall be performed.

Contact Info

First Name

Last Name

Middle Name

Date Of Birth

Gender

Home Email Address

Home Phone Number

Pager/Answering Service

Home Street Address

City

State

Zip Code

Qualifications

Professional Degree

DPM

DDS

DMD

CNP

CNMW

Other

Other Degree

State License Number

NPI - Individual

Relevant Training, Skills, And/Or Experience

Usual Practice Location

Institution/Group/Clinic Name (if applicable)

Office Manager

Street Address

City

State

Zip Code

Phone Number

Fax Number

Usual Scope Of Practice

Proposed COVID-19 Practice Location

Institution/Group/Clinic Name (if applicable)

Office Manager

Street Address

City

State

Zip Code

Phone Number

Fax Number

Proposed COVID-19 Clinical Services

Certification

I certify that:

I WILL BE PROVIDING CARE TO A PERSON WHO IS, OR WHO MAY REASONABLY BE BELIEVED TO BE, INFECTED WITH COVID-19 VIRUS.

THE CLINICAL SERVICES WILL MATERIALLY FURTHER THE STATE INTEREST IN PUBLIC HEALTH AND WELFARE IN RESPONDING TO THE COVID-19 VIRUS.

I WILL PROVIDE CARE RELATED WITHIN MY SKILLS AND BACKGROUND THAT IS DURING NECESSARY TO PROVIDE CARE DURING THE PENDENCY OF THE EXISTING HEALTH EMERGENCY.

AN AUTHORIZED REPRESENTATIVE OF THE FACILITY HAS APPROVED THE ABOVE PROVIDER’S REQUST TO BE DESIGNATED AS A COVID-19 CREDENTIALED PROVIDER.

I CERTIFY THAT ALL INFORMATION SUBMITTED IN THIS APPLICATION IS CORRECT AND COMPLETE. I ACKNOWLEDGE THAT ANY MATERIAL MISSTATEMENTS IN OR OMISSIONS MAY CONSTITUTE CAUSE FOR DENIAL OF MY APPLICATION. I CONSENT TO THE RELEASE OF ALL INFORMATION THAT MAY BE RELEVANT TO AN EVALUATION OF MY CREDENTIALS. I RELEASE NMDOH FROM ANY AN ALL LIABILITY FOR THEIR ACTS PERFORMED IN GOOD FAITH AND WITHOUT MALICE IN OBTAINING INFORMATION AND EVALUATING MY CREDENTIALS.

Applicant's Name

Date

Signature

Thank You.