EMS Agency Application Package

The documents, information and forms on this page are for use by persons interested in becoming licensed as an Emergency Medical Service (EMS) agency and for entities that wish to renew their EMS agency license.  All required forms must be accurate and complete prior to submission to the local Office of EMS Program Representative.  The Office of EMS Program Representative in your area is the primary contact if you have additional questions or require further information.  In addition, please feel free to contact the Office of EMS at 1-800-523-6019 and speak with a representative from the Division of Regulation and Compliance staff.

Vehicle Checklist

• Non-Transport Vehicle Checklist
• Ambulance Vehicle Checklist
• Air Ambulance Required Contents

EMS Agency Application with Memorandum

• Application for EMS Agency License - Instructional Guide
• Application for EMS Agency License
• Application for EMS Agency License - Word 97 – 2003
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• Application for EMS Agency License - Word 2007 Format
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Program Representative Information

• Contact Information
• Regional Map

Regional Council Contact Information

OMD Information

• OMD Requirement with Smple Agreement
• OMD Endorsement Application

Vehicle Liability Requirements

Approve EVOC Course Memorandum

Pre-Hospital Patient Care

• EMS Medical Record Form - Sample
• EMS Medical Record Order Form

IRS Tax Exempt Letter - Sample

Regulations Governing EMS (January 2003)