CHT Renewal Application

In observation of Independence Day our office will be closed Thursday, July 4th and Friday, July 5th.

In observation of Independence Day our office will be closed Thursday July 4th and Friday July 5th.

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According to the New Mexico Nurse Practice Act, the definition of Board approval for nursing programs is an official or formal consent, confirmation or sanction.

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Home > CMA / CHT Programs > Certified Hemodialysis Technician Programs > CHT Renewal Application

Certified Hemodialysis Technician Programs
Certified Medication Aide Programs

RENEWAL APPLICATION

HEMODIALYSIS TECHNICIAN PROGRAMS

APPLICATION INSTRUCTIONS: The application is not complete until the application has been submitted and the application fee has been paid.

Complete and submit this online Renewal Application.
Pay the application fee. Complete the payment form and fax it to (505) 841-8347.


*	Date of application
*	Type of application
FACILITY INFORMATION
*	Legal name of facility
*	AKA or DBA name (N/A if not applicable)
*	Street address
*	City, State and Zip Code
*	Telephone number
*	Name of corporate or owner
*	Mailing address of owner (Street address or P.O. Box)
*	City, State and Zip Code
*	Name of facility Manager/Administrator
*	Telephone number of Manager/Administrator
*	Email address of Manager/Administrator
*	Name of Nurse Educator
*	Nurse Educator license number
*	Telephone number of Nurse Educator
*	Email address of Nurse Educator
*	Name of Medical Director
*	New Mexico Department of Health license number
*	Expiration date of current DOH license number
*	Date of last Board of Nursing survey (N/A if not applicable)
*	Does the program utilize Clinical Preceptors?	YES NO
AKNOWLEDGEMENTS AND ATTESTATION
*	Are there sufficient resources available to meet the needs and purpose of the program?	YES NO
*	I understand that 16.12.4.13 NMAC requires that certain program changes must be reported to the Board of Nursing for approval.	I agree
*	I affirm that the information provided is true and accurate. I understand the application is not complete until the application fee has been paid.	I agree
*	Submitted By: Name
*	Title
*	Date

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6/26/2019 - Las Cruces RAC meeting
7/1/2019 - Lactation Care Advisory Committee
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