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Welcome to the OEMS electronic forms page. Contained on this page are various forms and applications required for licensure of providers and vehicles. If you do not find a form you require, please call 609-633-7777.
| Application for New Providers |
| EMS-7 |
Application for Licensure-New Provider Mobility Assistance, Basic Life Support
and Specialty Care Transport Providers |
Word 147k |
PDF 60k |
| |
Information for Medicare & Medicaid Provider Enrollment |
Word 36K |
PDF 15K |
| |
Legal Notice: Moratorium on the Enrollment of Invalid Coach (MAV) Providers |
Word 36K |
PDF 15K |
| |
Insurance Requirements for Providers |
Word 36K |
PDF 15K |
| |
Standard Operating Procedure (SOP) Sample |
Word 65K |
PDF 37K |
| Basic Provider Forms |
| EMS-8 |
Vehicle Accident Report |
Word 47K |
PDF 21K |
| EMS-9 |
Application for Change in Vehicle Status |
Word 41K |
PDF 18K |
| EMS-10 |
EMT Verification Report |
Word 41K |
PDF 16K |
| EMS-12 |
Incident Report |
Word 38K |
PDF 18K |
| EMS-15 |
Application to Upgrade Provider License Classification |
Word 40K |
PDF 20K |
| EMS-22 |
Application for Licensure - New Vehicle |
Word 42K |
PDF 19K |
| EMS-37 |
Application for Change of Trade Name, Address, Contact Person or Telephone Number (With No Change of Ownership) |
Word 45K |
PDF 19K |
| EMS-38 |
Staff Roster |
Word 147K |
PDF 28K |
| |
Application Instructions for EMS-37, Application for Change of Trade Name, Address, Contact Person or Telephone Number (With No Change of Ownership) |
Word 23K |
PDF 23K |
| Sample Inspection Forms |
| EMS-16 |
Survey Report for Mobility Assistance Vehicle |
Word 51K |
PDF 24K |
| EMS-19 |
Survey Report for Ambulance (Basic Life Support) |
Word 136K |
PDF 49K |
| EMS-20 |
Survey Report for Ambulance (Advanced Life Support-Non Transport) |
Word 136K |
PDF 50K |
| EMS-21 |
Survey Report for Ambulance (Advanced Life Support - Transport) |
Word 180K |
PDF 61K |
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Mobile Intensive Care Unit (under development) |
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Speciality Care Transport Unit (under development) |
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| Quarterly Reports |
| EMS-24 |
Quarterly Report of Mobile Intensive Care Program
Instructions for completion:
doc 89k pdf 66k |
Word 248K |
PDF 61K |
| EMS-25 |
Quarterly Report of Specilty Care Transport Units
Instructions for completion:
doc 43k pdf 27k |
Word 80K |
PDF 38K |
| EMS-26 |
Quarterly Report of Basic Life Support Ambulances Providing Emergency Response |
Word 91K |
PDF 36K |
| EMS-27 |
Quarterly Report of Air Medical Units |
Word 45K |
PDF 116K |
Training Fund Forms and Information
The following information and forms relate to the EMT Training Fund's continuing education course reimbursement process. These are the current information and forms which are needed. Copies are available in PDF format for download. If you have any further questions about the continuing education process, refer to other sections of this web site or call the Office of EMS.
Copies of the Eligibility Form and Scannable Sign-In Sheet must be attached to the Reimbursement Form when submitting for payment. Unfortunately, there can be NO EXCEPTIONS due to the error rate being submitted by the Instructors and Coordinators of these courses.
Basic Course Reimbursement
Information and Forms |
| |
EMT Training Fund Basic Course Reimbursement Procedure |
|
PDF 7K |
| EMS-43 |
EMT Basic Course Application and Schedule |
Word 128K |
PDF 50K |
| EMS-52 |
EMT Basic Course Payment Voucher |
Word 147K |
PDF 41K |
| EMS-53 |
EMT Training Fund Basic Course Reimbursement Report Form |
Word 31K |
PDF 27K |
| EMS-80 |
EMT Training Fund, "Certificate of Eligibility for an EMT Basic Course"
Instructions for completion: These forms are for candidates entering an EMT Basic course and qualify for reimbursement through the EMT Training Fund. Please complete this form and give to an officer in charge of training in your organization and have them sign it. Once completed, present it to the course coordinator of the program you are attending. |
Word 27K |
PDF 23K |
Continuing Education Reimbursement
Information and Forms |
| |
Application for Approval of Continuing Education Course |
Word 37K |
PDF 51K |
| |
EMT Training Fund Continuing Education Course Reimbursement Procedure |
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PDF 60K |
| |
EMT Training Fund Continuing Education Course Reimbursement Report |
|
PDF 61K |
| EMS-51 |
EMT Continuing Education Course Payment Voucher |
Word 147K |
PDF 41K |
| EMS-81 |
EMT Training Fund, "Certificate of Eligibility for a Continuing Education Course"
Instructions for completion: These forms are for candidates entering an EMT continuing education course and qualify for reimbursement through the EMT Training Fund. Please complete this form and give to an officer in charge of training in your organization and have them sign it. Once completed, present it to the course coordinator of the program you are attending. |
Word 28K |
PDF 23K |
| Other Related Forms |
| Annual Usage Form |
PDF 8K |
| Instructions for Completing the W-9 Vendor Questionnaire |
PDF 12K |
| W-9 Vendor Questionnaire [2 pages] [Please download and use this copy of the form] |
PDF 364K |
Request Materials
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