Forms

Forms & Documents

Quality Management Toolbox

Commercial Ambulance Applications & Forms

	Title	Description
	2013 Ground Annual Renewal Application	2013 Ground Annual Renewal Inspection Application
	Add Vehicle Application	Application to add a vehicle.
	Commercial Air Ambulance Service Licensing Application	Commercial Air Ambulance Service Licensing Application
	Equipment List	MIEMSS/SOCALR Equipment List 2013
	Fee Schedule	Fiscal year 2013 price list for Commercial Ambulance Licensing & Regulation.
	Fee Worksheet	Vehicle Fee Worksheet
	Medical Director Agreement	The medical director agreement.
	Neonatal Application and Equipment List	The neonatal application and equipment checklist.
	Neonatal Checklist	Neonatal Equipment Checklist
	Personal Injury Report Form	The Personal Injury Report Form.
	Personnel List	The personnel list.
	Service Application	Commercial Ambulance Services Licensing Application.
	Specialty Care Application and Equipment List	The specialty care application and equipment checklist.
	Specialty Care Checklist	Specialty Care Equipment Checklist
	Transfer Vehicle License Application	The application to transfer vehicle license.
	Upgrade/Downgrade Vehicle Application	Application to upgrade/downgrade vehicle license.
	Vehicle Collision & Personal Injury Report Form	The Vehicle Collision & Personal Injury Report Form.

EMS Provider Forms

	Title	Description
	Affiliation & Student Application Release Form	Maryland Emergency Services Student Application Release and Affiliation Form.
	ALS Class Application	Advanced Life Support Application Timelines and the ALS Program Course Approval Application.
	Change of Information	This form is to be used for pre-hospital providers who wish to document a change in name, address, or social security number.
	Course Request Form	This form is to be used by instructors and/or sponsoring agencies when requesting a BLS course. Must be received at least 20 days prior to class start date.
	CRT-99 with National Registry Relicensing Application	Cardiac Rescue Technician License Renewal Application. For use ONLY by CRT's having National Registry EMT-Intermediate/99 Certification.
	CRT-99 WITHOUT National Registry Relicensing Application	Cardiac Rescue Technician License Renewal Application. For use ONLY by CRT's NOT having National Registry EMT-Intermediate/99 Certification and originally licensed before July 1, 2001.
	Emergency Medical Technician Certification Renewal Application	Emergency Medical Technician Certification Renewal Application. For use ONLY by EMT's having National Registry EMT Certification. This application MUST be received by MIEMSS at least 14 days prior to expiration of your current EMT Certification.
	Extension Request	Form for requesting an extension of pre-hospital provider's license or certification. Must be received prior to current license/certification expiration date.
	Maryland EMS Continuing Education Course Application	This form is to be used by instructors and/or sponsoring agencies when requesting a Continuing Education number. Must be received at least 14 days prior to class start date.
	Paramedic Relicensing Application	Paramedic License Renewal Application. This application MUST be received by MIEMSS at least 14 days prior to expiration of your current Paramedic license.
	Preliminary EMS Report - Short Form 2012	MIEMSS Short Form Patient Information Sheet
	Surrender Form	This form is to be utilized by Maryland pre-hospital providers when requesting to surrender their current license/certification.

Others

Application for Participation in an Optional/Pilot Program

COMAR Order Form

Maryland Medical Orders for Life Sustaining Treatment (MOLST)

MD Facility AED Report Form for Cardiac Arrests

Proposed Protocol Submission Request Policy and Template