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S-SV EMS Agency
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Table of Contents
100 – State Law & Regulation
200 – Local EMS Agency (LEMSA)
300 – Hospitals
400 – Provider Agencies
500 – Patient Destination
600 – Documentation & QI
700 – Equipment & Supplies
800 – Field Policies & Treatment Protocols
900 – EMS Personnel
1000 – Training Programs
1100 – Procedure Policies
Protocols (ALS/BLS)
Cardiovascular (ALS/BLS)
Respiratory (ALS/BLS)
Medical (ALS/BLS)
Neurological (ALS/BLS)
OB/GYN (ALS/BLS)
Environmental (ALS/BLS)
Trauma (ALS/BLS)
Pediatric (ALS/BLS) Protocols
Protocols (LALS)
Cardiovascular (LALS)
Respiratory (LALS)
Medical (LALS)
Neurological (LALS)
OB/GYN (LALS)
Environmental (LALS)
Trauma (LALS)
Pediatric (LALS) Protocols
HPP
MICN Reauthorization Application
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Middle
Last
Mailing Address
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Address Line 1
City
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Email Address
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Telephone Number
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California RN License Number
*
California RN License Expiration Date
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S-SV MICN Authorization Expiration Date
S-SV EMS Base Hospital Employer
*
How Many Application File Attachments Do You Have To Upload? (3 MB Max File Size Per Attachment)
1
2
3
4
5
6
7
8
9
Please see "Reauthorization Instructions" on the previous page for a list of required documents. Any documents that are unable to be uploaded can be e-mailed to our mailbox: INFO @ ssvems.com
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Electronic Signature
By typing my name in the signature box and entering today's date, I hereby certify under penalty of perjury that all information on this application is true and correct to the best of my knowledge and belief, and I understand that any falsification or omission of material facts may cause forfeiture on my part of all rights to MICN Authorization by the S-SV EMS Agency. I understand all information on this application is subject to verification, and I hereby give my express permission for the S-SV EMS Agency to contact any person or agency for information related to my role and function as a MICN in the S-SV EMS Region.
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