New Mexico Caregiver's Authorization Affidavit Form - Free Download
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New Mexico Caregiver's Authorization Affidavit Form
New Mexico Caregiver
Caregiver’s Affidavit
This declaration does not affect the rights of the minor’s parents or
legal guardian regarding the care, custody and control of the minor.
This declaration does not mean that the caregiver has legal custody
of the minor.
A person who relies on this affidavit has no obligation to make any
further inquiry or investigation.
This affidavit is valid for one year from the date on which it is
Caregiver for purposes of this Act means, an adult, who is not a parent
of the child, with whom a child resides and who provides that child
with the care, maintenance and supervision consistent with the
duties and responsibilities of a parent of the child.”
Qualified Relative for purposes of Item 5, means a spouse, parent,
stepparent, brother, sister, stepbrother, stepsister, half-brother, half-
sister, uncle, aunt, niece, nephew, first cousin, godparent, member of
the child’s tribe or clan, an adult with whom the child has a
significant bond or any person denoted by the prefix “grand” or
“great”, or the spouse or former spouse of any of the persons
specified in this definition.
School-related medical care for purposes of Items 1-4 , means medical
care that is required by the state or a local government authority as a
condition for school enrollment.
If the minor stops living with you, you are required to notify any school,
health care provider, mental health care provider, health insurer or
other person to whom you have given this affidavit.
If you do not have the information requested in Item 8, provide another
form of identification such as your social security number or
Medicaid number.
No person who acts in good faith reliance upon a caregiver’s authorization
affidavit to provide medical, dental or mental health care, without actual
knowledge of facts contrary to those stated on the affidavit, is subject to criminal
liability or to civil liability to any person, or is subject to professional disciplinary
action, for such reliance if the applicable portions of the form are completed.
This affidavit does not confer dependency for health care coverage purposes.
This Form is authorized by New Mexico Statute: 40-10B-15 NMSA 1978.
June 2011
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New Mexico Caregiver's Authorization Affidavit Form