New Mexico Application to Medical Review Commission (Certificate of Merit Equivalent)

APPLICATION TO THE NEW MEXICO MEDICAL REVIEW COMMISSION

I. APPLICANT / CLAIMANT INFORMATION

Patient (Claimant) Name: [_______________________________]

Date of Birth: [__/__/____]

Address: [_______________________________]

City / State / ZIP: [_______________________________]

Telephone: [(___) ___-____]

Email: [_______________________________]

☐ The Application is signed by the patient.
☐ The Application is signed by the patient's attorney on the patient's behalf.
☐ The Application is signed by [legal guardian / conservator / personal representative] for the [minor / incapacitated / deceased] patient.

If patient is a minor: Date of birth: [__/__/____]; current age: [____]; legal representative: [_______________________________].

If patient is deceased: Date of death: [__/__/____]; Personal Representative: [_______________________________]; Letters of Administration attached: ☐ Yes ☐ Pending.

II. RESPONDENT HEALTH CARE PROVIDER(S)

For each provider against whom this Application is directed, provide the information below. Add additional sheets as needed.

Provider 1

Name: [_______________________________], [degree: M.D./D.O./other]

Specialty: [_______________________________]

License No. (NM): [_______________]

Practice / Employer: [_______________________________]

Address: [_______________________________]

Telephone: [(___) ___-____]

Qualified under MMA (§ 41-5-5)? ☐ Yes ☐ Unknown — please confirm with NM Superintendent of Insurance prior to hearing.

Type of provider:
☐ Independent qualified provider (subject to MRC under § 41-5-14)
☐ Hospital — NOT subject to MRC; do not submit to Commission
☐ Outpatient health care facility — NOT subject to MRC after 7/1/2021
☐ Other: [_______________________________]

Provider 2

(Repeat block as needed.)

III. STATEMENT OF JURISDICTION & TIMELINESS

1. The act(s) of alleged malpractice occurred on or about [__/__/____] at [_______________________________] in [_______________] County, New Mexico.

2. This Application is timely filed within the three-year limitations period of NMSA 1978, § 41-5-13. Tolling applies during the pendency of this panel review pursuant to NMSA 1978, § 41-5-22.

3. ☐ The patient is/was a minor; tolling rules of § 41-5-13 are invoked.

4. ☐ The patient is/was incapacitated; tolling rules of § 41-5-13 are invoked.

5. The Commission has jurisdiction under NMSA 1978, § 41-5-14, because the named Respondent(s) is/are independent qualified health care provider(s) under the New Mexico Medical Malpractice Act.

IV. BRIEF STATEMENT OF THE CASE

A. Background and Presentation

[_______________________________________________________________
_______________________________________________________________
_______________________________________________________________]

B. Course of Care and Specific Acts/Omissions Alleged

On [__/__/____], Respondent [PROVIDER NAME] [examined / treated / operated upon / prescribed for] the patient. The patient alleges the following deviations from the applicable standard of care:

• ☐ Failure to diagnose [_______________________________];
• ☐ Misdiagnosis as [_______________________________];
• ☐ Failure to order [diagnostic study / consultation];
• ☐ Improper performance of [procedure];
• ☐ Failure to obtain informed consent for [procedure];
• ☐ Improper medication selection / dose / contraindication: [_______________________________];
• ☐ Failure to monitor / failure to rescue;
• ☐ Failure to communicate critical findings;
• ☐ Other: [_______________________________].

C. Injury / Outcome

As a result of the above, the patient suffered:

• ☐ [_______________________________];
• ☐ [_______________________________];
• ☐ Death on [__/__/____].

D. Standard-of-Care Basis

The applicable standard of care is that of a [specialty] under the same or similar circumstances. The patient's expert(s), having reviewed the records, [are/will be] of the opinion that the Respondent(s) breached that standard and that the breach proximately caused the injury.

V. RECORDS LIST AND HIPAA AUTHORIZATION

A. Treating Providers / Custodians (list every relevant entity from whom records are sought):

B. HIPAA-Compliant Authorization — A separately executed authorization permitting the Commission, the panel, the Respondents, and counsel to obtain and review all relevant medical records is attached as Exhibit 1.

VI. RELIEF REQUESTED FROM THE COMMISSION

Pursuant to NMSA 1978, § 41-5-17, the Commission is requested to determine whether:

1. There is substantial evidence that the acts complained of occurred and that they constitute malpractice; and
2. There is a reasonable medical probability that the patient was injured thereby.

VII. CERTIFICATIONS

1. The undersigned certifies that, to the best of the undersigned's knowledge after reasonable inquiry, the allegations herein are true.

2. The undersigned acknowledges that the deliberations of the panel are confidential under NMSA 1978, § 41-5-19, and that no panel member, witness, or other participant shall be subject to civil action for any communication made in the proceeding.

3. The undersigned acknowledges that, pursuant to NMSA 1978, § 41-5-20, the panel's decision and the testimony before it are inadmissible in any subsequent civil action, except as expressly permitted by the statute.

4. The undersigned acknowledges that filing this Application does not constitute filing a complaint in district court and does not, by itself, satisfy filing requirements under NMRA.

VIII. SIGNATURE BLOCK

Respectfully submitted this [____] day of [_______], 20[__].

[LAW FIRM NAME]

By: __________________________________
[ATTORNEY NAME], Esq. (NM Bar No. [______])
[FIRM ADDRESS]
[CITY, NM ZIP]
Telephone: [(___) ___-____]
Email: [_______________________________]

Attorney for Patient/Claimant

OR (if filing pro se):

__________________________________
[PATIENT NAME], Pro Se

EXHIBIT 1 — HIPAA AUTHORIZATION (Attach as Separate Document)

I, [PATIENT NAME], born [__/__/____], authorize the use and disclosure of my protected health information, including all medical, billing, mental-health, substance-use, and HIV/AIDS-related records, to the New Mexico Medical Review Commission, the assigned panel members, the Respondent providers, their counsel, and counsel for the Patient/Claimant.

This authorization is governed by 45 C.F.R. § 164.508 and is intended to be HIPAA-compliant. It expires on [__/__/____] or upon written revocation.

Signature: ____________________________

Date: [__/__/____]

Witness: ____________________________

PROCEDURAL CHECKLIST — Pre-Filing

☐ Confirm Respondent's qualified-provider status with NM Superintendent of Insurance.
☐ Confirm Respondent is NOT a hospital or outpatient health care facility (post-7/1/2021 carve-out).
☐ Verify limitations period under § 41-5-13; calculate days remaining and tolling effect.
☐ Obtain expert review and confirm colorable malpractice opinion.
☐ Draft Application with brief but complete narrative.
☐ Draft HIPAA authorization.
☐ Compile records list with dates and custodians.
☐ Mail Application and authorization to Commission director (verify current address).
☐ Calendar 60-day hearing window and 7-business-day panel-pack deadline.
☐ Reserve three (3) peremptory challenges (must be filed at least 6 business days pre-hearing).
☐ On receipt of certified Commission decision, calendar resumption of § 41-5-13 clock (30 days after first attempted delivery).

NOTES FOR PRACTITIONERS

Sources and References

• NMSA 1978, §§ 41-5-14, 41-5-15, 41-5-16, 41-5-17, 41-5-18, 41-5-19, 41-5-20, 41-5-22 (current versions)
• HB 75 (2021 Regular Session); HB 11 (2021 Special Session)
• NM Medical Review Commission, Policies and Procedures (current edition)
• New Mexico Medical Society — NMMRC overview
• State Bar of New Mexico — Medical Review Committee
• NM Superintendent of Insurance — Qualified Provider Roster