New Mexico Adult Protective Services Report (Mandatory Reporter Form)

NEW MEXICO ADULT PROTECTIVE SERVICES REPORT

HOTLINE (call FIRST): 1-866-654-3219 (24 hours / 7 days)

Online intake: report through the New Mexico Aging & Long-Term Services Department (ALTSD) APS portal.

Emergencies / immediate danger: call 911 first.

TABLE OF CONTENTS

1. Reporter Information
2. Adult at Risk — Identifying Information
3. Caretaker / Household / Suspected Perpetrator
4. Statutory Basis for Report
5. Nature and Extent of Suspected Abuse, Neglect, or Exploitation
6. Basis of Reporter's Knowledge and Evidence
7. Immediate-Danger and Safety Assessment
8. Cross-Reports to Law Enforcement and Other Agencies
9. Confidentiality, HIPAA, and Immunity
10. Reporter Certification and Signature
11. APS Internal Use — Intake Acknowledgment
12. New Mexico Practice Notes
13. Sources and References

1. REPORTER INFORMATION

2. ADULT AT RISK — IDENTIFYING INFORMATION

2.1. Name of adult. [________________________________].

2.2. Other names known by / preferred pronouns. [________________________________].

2.3. Date of birth. [__/__/____] Approximate age: [____].

2.4. Current physical location (residence, hospital, nursing facility, ALF, hotel, homeless camp, etc.):

[________________________________]

2.5. Mailing address (if different). [________________________________].

2.6. Phone (if any). [________________________________].

2.7. Tribal affiliation / Pueblo / Nation (if any). [________________________________].

2.8. Languages spoken / interpreter need. [________________________________].

2.9. Capacity status — basis to believe the adult is "incapacitated" within the meaning of NMSA § 27-7-16(B):

• ☐ Cognitive impairment (dementia, Alzheimer's, TBI, intellectual disability)
• ☐ Severe and persistent mental illness
• ☐ Physical disability impairing self-protection
• ☐ Advanced age with frailty
• ☐ Court-adjudicated incapacity / under guardianship
• ☐ Other: [________________________________]

2.10. Known medical conditions, medications, mobility status. [________________________________].

3. CARETAKER / HOUSEHOLD / SUSPECTED PERPETRATOR

3.1. Primary caretaker.

3.2. Suspected perpetrator (if different from caretaker, or if more than one).

3.3. Other household members. [LIST NAMES, AGES, RELATIONSHIPS].

3.4. Power of attorney, guardian, or conservator (if known). [________________________________].

4. STATUTORY BASIS FOR REPORT

Check each category that applies and complete the corresponding narrative in Section 5.

• ☐ Abuse — physical (NMSA § 27-7-16(A)(1)): the knowing, intentional, or negligent infliction of physical pain or injury without justifiable cause.
• ☐ Abuse — sexual (NMSA § 27-7-16(A)(2)): criminal sexual contact, criminal sexual penetration, or other sexual offense.
• ☐ Abuse — psychological / mental anguish (NMSA § 27-7-16(A)(1)): infliction of mental anguish, intimidation, isolation, or threats.
• ☐ Abuse — caretaker (NMSA § 27-7-16(A)): unreasonable confinement, deprivation, or use of psychotropic restraint.
• ☐ Neglect (NMSA § 27-7-16(D)): failure of caretaker to provide for basic needs — food, shelter, clothing, supervision, medical or mental-health care — resulting in or likely to result in harm.
• ☐ Self-neglect (NMSA § 27-7-16(E)): inability of an incapacitated adult to perform essential self-care, presenting risk of serious harm.
• ☐ Exploitation (NMSA § 27-7-16(C)): unjust or improper use of an incapacitated adult's money, property, or person for another's profit or advantage; misuse of a power of attorney; theft; undue influence; financial fraud or scam.
• ☐ Abandonment: caretaker desertion of an incapacitated adult.

5. NATURE AND EXTENT OF SUSPECTED ABUSE, NEGLECT, OR EXPLOITATION

5.1. Date(s), time(s), and location(s) of incident(s).

[________________________________]

5.2. Detailed factual narrative. State only what was observed, heard, measured, photographed, or documented. Distinguish first-hand observation from reports made by others. Avoid conclusions of law.

[________________________________]

[________________________________]

[________________________________]

5.3. Physical findings (if observed).

5.4. Statements by the adult (verbatim where possible). [________________________________]

5.5. Statements by witnesses. [NAME, RELATIONSHIP, CONTACT, STATEMENT]

5.6. Pattern / prior incidents. [DESCRIBE OR "NONE KNOWN"]

5.7. Financial-exploitation specifics (if applicable).

6. BASIS OF REPORTER'S KNOWLEDGE AND EVIDENCE

6.1. How did you become aware? ☐ Direct observation ☐ Disclosure by adult ☐ Disclosure by family/friend ☐ Medical record review ☐ Bank/financial record review ☐ Other professional referral ☐ Other: [____].

6.2. Records, photographs, or recordings available (do NOT include with this form unless APS requests; describe and retain securely):

• ☐ Medical records / chart notes
• ☐ Photographs (date-stamped)
• ☐ Audio / video recording
• ☐ Bank statements
• ☐ Police report number [____]
• ☐ Hospital admission record
• ☐ Other: [________________________________]

6.3. Additional witnesses or collateral contacts. [NAMES AND PHONE NUMBERS]

7. IMMEDIATE-DANGER AND SAFETY ASSESSMENT

7.1. Is the adult in immediate danger of serious physical harm or death? ☐ YES — call 911 NOW ☐ No ☐ Unknown.

7.2. Is the suspected perpetrator currently with the adult? ☐ Yes ☐ No ☐ Unknown.

7.3. Does the adult have access to food, water, heat, medications, and a phone? ☐ Yes ☐ No — describe: [____].

7.4. Has the adult been refused medical care? ☐ Yes ☐ No.

7.5. Weapons / firearms in the home? ☐ Yes ☐ No ☐ Unknown.

7.6. Recommended immediate actions taken by reporter (e.g., called 911, escorted to ER, secured medications, notified family). [________________________________]

8. CROSS-REPORTS TO LAW ENFORCEMENT AND OTHER AGENCIES

9. CONFIDENTIALITY, HIPAA, AND IMMUNITY

9.1. Confidentiality of report. APS records are confidential under NMSA § 27-7-30(C) and 8.11 NMAC. The identity of the reporter is protected and is generally not disclosed to the alleged perpetrator.

9.2. HIPAA. Reporting suspected abuse, neglect, or exploitation of an incapacitated adult to a public-health authority is a permitted disclosure under 45 C.F.R. § 164.512(b) and (c). State-mandated reporting also satisfies the "required by law" exception in 45 C.F.R. § 164.512(a). HIPAA does not bar this report.

9.3. Statutory immunity (NMSA § 27-7-31). A reporter, witness in proceedings arising from the report, or person providing records or participating in an evaluation in good faith is IMMUNE from civil and criminal liability arising from the report, testimony, or participation, unless the person acted in bad faith or with malicious purpose.

9.4. Penalties for failure to report (NMSA § 27-7-30(D)). Failure or refusal to report, or obstruction or impediment of an APS investigation, is a misdemeanor; the Department may also assess a civil penalty up to $10,000 per violation.

9.5. Retaliation prohibited. Retaliation by an employer or facility against a reporter is prohibited under NMSA § 27-7-30 and federal law where the reporter is also a healthcare worker (42 U.S.C. § 1395i-3(b)(3)(F) — Nursing Home Reform Act).

10. REPORTER CERTIFICATION AND SIGNATURE

I certify that the information stated above is true and correct to the best of my knowledge and belief, and that I have made or am making this report in good faith pursuant to NMSA § 27-7-30. I understand that any willfully false statement to a state officer is a violation of NMSA § 30-22-5 (false statement to a peace officer) and may subject me to criminal and civil liability.

Reporter signature: [________________________________] Date: [__/__/____]

Printed name: [________________________________]

Sworn to and subscribed (where required for litigation use) before me this [____] day of [_______________], 20[____].

[________________________________]

Notary Public — State of New Mexico

(My Commission Expires: [_______________])

11. APS INTERNAL USE — INTAKE ACKNOWLEDGMENT

12. NEW MEXICO PRACTICE NOTES

• Universal duty. Unlike many states that limit mandatory reporting to enumerated professionals, NMSA § 27-7-30 imposes the duty on "any person, or financial institution." The standard is "reasonable cause to believe" — not certainty, not corroboration.
• No delay. The statute requires "immediate" reporting. Prior consultation with risk management, counsel, or supervisors is not a precondition and cannot override the statutory duty. Document the call first; refine the written report afterward.
• Self-neglect cases. New Mexico expressly authorizes APS to investigate self-neglect of incapacitated adults. Capacity, not autonomy, drives the analysis.
• Financial-institution duty. Banks, credit unions, and broker-dealers have an affirmative reporting obligation when they have reasonable cause to suspect exploitation, in addition to any Suspicious Activity Report obligations under 31 C.F.R. § 1020.320.
• Long-term-care facility incidents. Suspected abuse / neglect of a nursing-home, assisted-living, or ICF/IID resident requires parallel reporting to the Department of Health Division of Health Improvement (1-800-752-8649) and triggers federal nursing-home reporting under 42 U.S.C. § 1395i-3(b)(3)(F) and 42 C.F.R. § 483.12. The State Long-Term Care Ombudsman (1-866-451-2901) is also available to advocate on behalf of the resident.
• Tribal jurisdiction. Where the adult resides on tribal land, federal-tribal-state jurisdictional rules apply. Cross-report to tribal social services and, where applicable, to the BIA / IHS Office of the Inspector General.
• Criminal exposure for perpetrators. Conduct may also violate NMSA § 30-3-19 (crimes against an at-risk adult) and other criminal statutes; APS coordinates with law enforcement and the Office of the Attorney General Medicaid Fraud Control Unit for facility cases.
• Records preservation. Preserve photographs, video, and originals; do not alter dates or annotations. Keep a copy of this report and all supporting records in a secure file separate from routine clinical or business records.
• Ethics and licensing. Healthcare and licensed-professional reporters should also follow internal facility policies and applicable licensure-board reporting rules but must not allow internal review to delay APS notification.

13. SOURCES AND REFERENCES

• New Mexico Aging & Long-Term Services Department — Protecting Adults / APS — https://www.aging.nm.gov/protecting-adults/
• ALTSD APS reporting overview — https://altsd.nm.gov/protecting-adults/
• NMSA § 27-7-30 (Duty to report; penalty) — https://law.justia.com/codes/new-mexico/chapter-27/article-7/section-27-7-30/
• NMSA § 27-7-31 (Immunity)
• NMSA § 27-7-16 (Definitions)
• NMSA § 30-3-19 (Crimes against an at-risk adult)
• 8.11 NMAC (APS Program rules)
• New Mexico Department of Health, Division of Health Improvement — Health Facility Complaint hotline 1-800-752-8649 — https://www.hca.nm.gov/division-of-health-improvement/
• State Long-Term Care Ombudsman Program — 1-866-451-2901 — https://www.aging.nm.gov/ombudsman/
• 45 C.F.R. § 164.512(a)–(c) (HIPAA permitted disclosures)
• 42 U.S.C. § 1395i-3(b)(3)(F) (federal nursing-home reporting)
• 42 C.F.R. § 483.12 (federal nursing-home abuse / neglect requirements)

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Reports must be made immediately by phone or online portal to the New Mexico Adult Protective Services Statewide Intake at 1-866-654-3219. This written form supplements but does not replace the statutory call. Have an attorney licensed in New Mexico review for specific privilege, HIPAA, and confidentiality questions.