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Department of Health Forms Commonly Used by EMS Providers

The forms listed below are the ones most commonly used by EMS providers and agencies. We have placed these files here to assist you.

For additional assistance contact the Bureau of EMS or your Regional EMS Representative.

Vouchers

• Agency Claim for Payment Voucher - AC3253-S (PDF)
• Course Sponsor Claim for Payment Voucher - AC3253-S (PDF)
• Proctor Claim for Payment for Non-State Employees - AC3253-S (PDF)

EMS Operations

Investigations

• Reportable Incident Report (PDF)
• EMS Complaint Form (PDF)

EMS Provider

• EMS Provider Reporting Long Wait Times at Hospital
• EMS Agency Leader and EMS Provider to Sign Up for Bureau Briefings
• EMS Agency Leader and EMS Provider Briefing Question Submissions
• ePCR Issues Reporting Form

Agency

• DOH-2596 Inspection Report for Certified Ambulance Vehicles (PDF)
• DOH-5136 Application and Approval for EMS Agency to Use e-PCR (PDF)
• DOH-206 Application for EMS Operating Certificate (PDF)
• DOH-1881 Affirmation of Compliance (PDF)
• DOH-2828 EMS Agency Personnel Roster (PDF)
• DOH-2936 Certified EMS Agency Information Update Form - Fillable (PDF)
• DOH-3777 Application for New EMS Service, Expansion of Territory or Transfer of Ownership (PDF)
• DOH-3778 Affirmation of Fitness and Competency - Fillable (PDF)
• DOH-3780 Inspection Report for BLSFR Vehicle or EASV - Fillable (PDF)
• DOH-4362 Medical Director Affirmation Form - Fillable (PDF)
• DOH-4461 Reportable Incident Form (PDF)
• DOH-5127 BLSFR Agency Information Application/Update Form (PDF)
• DOH-5131 Funding Document For EMS Agencies - Fillable (PDF)
• DOH-5208 Notice of Intent to Provide Ambulance Transfusion Services - (PDF)
• DOH-5209 Blood Transfusion Record - (PDF)
• DOH-5210 Blood Transfusion Transfer Orders - (PDF)
• Rotary Wing AMS Equipment Waiver Approval (PDF)
• Clinical Laboratory Evaluation Program - Permit Application Materials
• Clinical Laboratory Evaluation Program (CLEP) – Blood Glucose Testing
• DOH-4081 Limited Lab Application Form for EMS Agencies
• DOH-4081 Instructions & Schedule of Fees for Application

Controlled Substances

• DOH-2094 Loss of Controlled Substances Report (PDF)
• DOH-3826 Application for ALS Agency to Engage in Controlled Substances Activity for Pre-Hospital Care (PDF)
• DOH-3827 Application to be a Controlled Substance Agent for an ALS Agency (PDF)
• DOH-3848 Controlled Substance Report for Emergency Medical Services Agencies (PDF)
• DOH-3850 Stock Inventory (PDF)
• DOH-3851 Controlled Substances Substock Inventory (PDF)
• DOH-4004 Controlled Substances Usage Verification (PDF)

EMS Education and Certification

Education

• AEMT Rapid Recertification Administrative Manual (PDF)
• DOH-89 Certified Class List for Ancillary EMS Training Courses (PDF)
• DOH-80 Notice of Course Cancellation (PDF)
• DOH-263 Course Memorandum (PDF)
• DOH-743 Instructor Information Sheet (PDF)
• DOH-2423 Lab Instructor Audit Report (PDF)
• DOH-2424 Didactic Presentation Audit Report (PDF)
• DOH-2733 Final Practical Skills Examination Summary Sheet (PDF)
• DOH-3377 CIC Internship Completion Report (PDF)
• DOH-3378 CLI Internship Completion Report (PDF)
• DOH-4297 Course Assistant Medical Director Form (PDF)
• DOH-4451 CLI Internship Tracking Form (PDF)
• DOH-4452 CIC Internship Tracking Form (PDF)

Certification

• DOH-65 Application for Emergency Medical Services Certification (PDF)
• DOH-79 Students Ineligible To Take The State Certifying Examination (PDF)
• DOH-2260 Application for Instructor Certification (PDF)
• DOH-3312 Verification of Membership in A NYS EMS Agency (PDF)
• DOH-3379 Medical Director's Certification of AEMT Course Completion (PDF)
• DOH-4010 Application for AEMT Rapid Recertification (PDF)
• DOH-4245 Registration For Emergency Medical Technicians' Exam, Test Scheduling Request (PDF)
• DOH-4260 Registration For On-Site Scored NYS Written Certification Exams (PDF)
• DOH-4281 Certification Extension for Military Personnel (PDF)
• DOH-4453 Name or Address Change and Duplicate Card Requests (PDF)

CME Pilot Recertification Program

All recertification forms must be postmarked no later than 45 days prior to your expiration date.

• DCME Certification Renewal Cover Sheet - To be used for all levels of CME renewal (PDF)
• DOH-4227 Agency Registration Form (PDF)
• DOH-5065 EMT Recertification Form
• DOH-5066 AEMT Critical Care Recertification Form
• DOH-5067 AEMT Recertification Form
• DOH-4231 Paramedic Recertification Form

Miscellaneous Forms

Part 18 - Public Gathering and Public Function

• DOH-44 Application for a Permit for a Public Gathering (PDF)
• DOH-2332 Part 18 Public Function Event Report (PDF)
• DOH-2342 Part 18 Public Function Medical Incident Log (PDF)

Do Not Resuscitate (DNR) Order/MOLST

• DOH-3474 Nonhospital Order Not To Resuscitate (DNR Order) (PDF)
• DOH-3474es Nonhospital Order Not To Resuscitate, Spanish Version (DNR Order) (PDF)
• DOH-5003 Medical Orders for Life-Sustaining Treatment (MOLST) (PDF)

Notices of Intent

• DOH-4135 Notice of Intent to Provide Public Access Defibrillation (PAD) (PDF)
  • PAD Collaborative Agreements (DOC)