Section 40-10B-15 - Caregiver's authorization affidavitA. A caregiver who executes a caregiver's authorization affidavit substantially in the form contained in Subsection J of this section by completing Items 1 through 4 of the form and who subscribes and swears to it before a notary public, is authorized to:(1) enroll the named child in early intervention services, child development programs, headstart, preschool or a kindergarten through grade twelve school;(2) consent to medical care, including school-related medical care, immunizations, sports physical examinations, dental care and mental health care; and(3) be the authorized contact person for school-related purposes.B. A caregiver who is a relative of the child, who executes a caregiver's authorization affidavit substantially in the form set forth in Subsection J of this section by completing Items 1 through 7 and who subscribes and swears to the affidavit before a notary public, has the same authority to authorize medical care, dental care and mental health care for the child as a guardian appointed pursuant to the Kinship Guardianship Act.C. A caregiver's authorization affidavit executed pursuant to this section is not valid for more than one year after the date of its execution.D. The decision of a caregiver to consent to or refuse medical, dental or mental health care pursuant to a caregiver's authorization affidavit is superseded by a contravening decision of a parent or other person having legal custody of the child if the contravening decision does not jeopardize the life, health or safety of the child.E. No person who acts in good faith reliance on a caregiver's authorization affidavit to provide medical, dental or mental health care to a child without actual knowledge of facts contrary to those stated in the affidavit is subject to criminal culpability, civil liability or professional disciplinary action if the affidavit complies with the requirements of this section. The foregoing exclusions apply even though a parent having parental rights or person having legal custody of the child has contrary wishes as long as the provider of the care has no actual knowledge of the contrary wishes.F. A person who relies upon a caregiver's authorization affidavit is under no duty to make further inquiry or investigation.G. If a child stops living with the caregiver, the caregiver shall give notice of that fact to a school, early intervention services provider, child development program provider, headstart provider, preschool or kindergarten through grade twelve school, medical or dental health care provider, mental health care provider, health insurer or other person who has been given a copy of the caregiver's authorization affidavit.H. A caregiver's authorization affidavit is invalid unless it contains the warning statement set out in the form contained in Subsection J of this section in not less that ten-point boldface type, or a reasonable equivalent thereof, enclosed in a box with three-point rule lines.I. As used in this section, "school-related medical care" means medical care that is required by the state or a local government authority as a condition for school enrollment.J. The caregiver's authorization affidavit shall be in substantially the following form: "Caregiver's Authorization Affidavit"
Use of this affidavit is authorized by the Kinship Guardianship Act.
Instructions:
A. Completion of Items 1-4 and the signing of the affidavit is sufficient to authorize the caregiver to:(1) enroll a minor in early intervention services, child development programs, headstart, preschool or a kindergarten through grade twelve school ("school");(2) consent to medical care, including school-related medical care, immunizations, sports physical examinations, dental care and mental health care; and(3) be the authorized contact person for school-related purposes.B. Completion of Items 5-7 is additionally required to authorize any other medical care. Print clearly:
The minor named below lives in my home and I am 18 years of age or older.
1. Name of minor: _____________________________.2. Minor's birth date: _____________________________.3. My name (adult giving authorization): _____________________________.4. My home address: _____________________________.5. Check one or both (for example, if one parent was advised and the other cannot be located): ( ) I have advised the parent(s) or other person(s) having legal custody of the minor of my intent to authorize medical care, and have received no objection.
( ) I am unable to contact the parent(s) or other person(s) having legal custody of the minor at this time, to notify them of my intended authorization.
6. My date of birth: _________________________________________.7. My NM driver's license or other identification card number: ________________________.
WARNING: Do not sign this form if any of the statements above are incorrect, or you will be committing a crime punishable by a fine, imprisonment or both.
I declare under penalty of perjury under the laws of the state of New Mexico that the foregoing is true and correct.
Signed: _____________________________
The foregoing affidavit was subscribed, sworn to and acknowledged before me this _____ day of _________________, 20_____, by _____________________.
My commission expires: ______________ _____________________________
Notary Public
Notices:
1. This declaration does not affect the rights of the minor's parents or legal guardian regarding the care, custody and control of the minor and does not mean that the caregiver has legal custody of the minor.2. A person who relies on this affidavit has no obligation to make any further inquiry or investigation.3. This affidavit is not valid for more than one year after the date on which it is executed. Additional Information:
TO CAREGIVERS:
1. If the minor stops living with you, you are required to notify any school, early intervention services provider, child development program provider, headstart provider, preschool or kindergarten through grade twelve school, medical or dental health care provider, mental health care provider, health insurer or other person to whom you have given this affidavit.2. If you do not have the information requested in Item 7, provide another form of identification such as your social security number or medicaid number. TO HEALTH CARE PROVIDERS AND HEALTH CARE SERVICE PLANS:
1. 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.2. This affidavit does not confer dependency for health care coverage purposes. Laws 2001, ch. 167, § 15; 2017, ch. 62, § 1.Amended by 2017, c. 62,s. 1, eff. 6/16/2017.