NMSU LC

NMSU Las Cruces Employee

Immunization Request Form

Next Clinic Date TBA

Campus Health Center

3080 Breland Drive

________________________________________________________________

Online signups are now closed.

However, you may print the following

form to be turned in at the above clinic:

Paper Request Form

*In order to open this Immunization Request Form you must have Adobe

Acrobat Reader. To download this free program please click the link below:

________________________________________________________________

You MUST present the following card in order to receive your vaccinations with no copay for you and/or insured dependents:

A Medco Rx prescription card

(pictured left) provided by the New Mexico Public Schools Insurance Authority or the State of New Mexico.

As this is a benefit of the prescription insurance coverage, those not covered under one of the above insurance program will be responsible for the cost of immunizations. You may follow the link below to view Cash pricing for all available vaccinations.

NO/OTHER Prescription Coverage? CLICK HERE to see pricing details.

Instructions:

If you have a Medco Health Prescription Card:
1. Fill out billing information for employee
2. Fill out employee immunization request
3. Fill out dependent family member immunization request
4. If you have more than 3 family members you will have to submit a second form.
5. You may click on the name of any vaccine to be redirected to a web site containing the vaccine information statement
6. * Fields are required

NO Prescription Coverage: CLICK HERE