Temporary Recognition of EMS Personnel Application

Applicant Information

Date *

Name *

First

Last

Email *

Phone *

Private EMS Provider Organization Information

Provider Organization Name *

Provider Organization Business Location *

Address Line 1

Address Line 2

City

State

Zip Code

Management Contact

Medical Director

Name *

First

Last

Name *

First

Last

Phone *

Phone *

Email *

Email *

Required Information/Documentation

Substances Director Medical

Quality Improvement / Control *

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Copy of the organization’s EMS quality improvement plan/process

Controlled Substances *

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Copy of the organization’s policy/process ensuring secure storage/handling of controlled substances (if applicable)

PCR Data Information *

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The organization’s EMS documentation & data collection policy/process and an explanation of how the organization will submit incident PCRs to S-SV EMS

Protocols *

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Identification of which patient care protocols will be utilized by the organization’s EMS personnel (State EMS protocols, EMS provider organization protocols, etc.)

Letter of Good Standing *

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A letter from the entity/state where the organization is authorized to provide EMS services, stating they are an authorized EMS provider in good standing

EMS Business License(s) *

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Copies of applicable EMS business license(s)/permit(s)

Electronic Attestation

I attest that all information contained on this form and attached documents is true and correct to the best of my knowledge. I further attest that our organization agrees to submit all incident related PCRs to S-SV EMS within 7 calendar days of incident demobilization, or within 24-hours of a request from an authorized S-SV EMS representative in response to an EMS complaint/investigation related to an incident. I further attest that any patient transport vehicle used in the provision of EMS services within the S-SV EMS region is mechanically sound and that our EMS personnel agree not to transport any patient from the incident directly to an acute care hospital without the direction/approval of the applicable IC, MedL, or authorized designee.

Name *

First

Last

Date *