Submit New Application

Request to become an Employer Application

Please complete this application to be listed as an eligible employer in TMU© to verify the employment of nurse aides for the renewal of their state nurse aide certification.

For a facility to be entered into the system as an employer, it must meet the following criteria:

Facility is licensed as a health facility through the State of New Mexico's Health Care Authority (HCA), Division of Health Improvement (DHI)
Nurse aides perform nursing or nursing-related services for pay
Nurse aides are under the supervision of an RN or LPN
Nurse aides complete a minimum of 12 hours of in-service training per year, which includes dementia and abuse/neglect/exploitation prevention training.

Name

Fax

Phone

Alt Phone

Administrator

Approval Number

Medicaid Number

Medicare Number

Address

City

State

Zipcode

Mailing Address

Address

City

State

Zipcode

Facility Contact Person

Contact Person's Name The contact person for your facility is responsible for verifying employment of nurse aides currently or previously employed (in the past 24 months) at your facility.

Position/Title Your contact person should be someone who has access to your facility's employee records so they can verify employment.

Email Address for Contact Person You will use this email address to log into your facility's employer account in TMU© if your application is approved.

Facility Licensure

Facility License Number Please provide your facility's license number. If you are unsure what your facility's license number is, please contact Health Facility Licensing & Certification at: facility.license@hca.nm.gov or visit https://www.hca.nm.gov/health-facility-licensing-and-certification/

Health Facility Type Please provide what type of health facility your facility is licensed as. For example: Hospice Agency, Home Health Agency, Nursing Facility, Skilled Nursing Facility, Hospital, etc.

Affidavit

I attest, under penalty of law, that the information provided is truthful and accurate to the best of my knowledge and that knowingly providing false information or omitting information may result in denial of licensure.

By Submitting

I hereby verify that I understand and agree with the statements contained herein and the above information is true and correct.