EMS Provider Forms

All EMS forms are available online at MIEMSSLicense.com, the MIEMSS Licensure System. We encourage everyone to use this web-based system, as it is the most expedient means of processing your request.

Preliminary EMS Report - Short Form 2012MIEMSS Short Form Patient Information Sheet

Commercial Ambulance Applications & Forms

Specialty Care ApplicationSpecialty care application
Specialty Care Equipment ListSpecialty Care Equipment List
Quality Assurance Officer Designation FormQuality Assurance Officer Designation Form
Neonatal Equipment ListNeonatal Equipment List
Personnel ListThe personnel list
Upgrade/Downgrade Vehicle ApplicationApplication to upgrade/downgrade vehicle license
Vehicle Collision & Personal Injury Report FormVehicle Collision & Personal Injury Rpt Form
Transfer Vehicle License ApplicationApplication to transfer vehicle license
Temporary Downgrade Request FormForm to request temporary downgrade
Temporary Upgrade Request FormForm to request temporary upgrade
Neonatal Application The neonatal application
Application for Participation in an Optional/Pilot ProgramParticipation in Optional/Pilot Program Form
BLS Equipment ListMIEMSS/SOCLAR BLS Equipment List 2018
ALS Equipment ListMIEMSS/SOCALR ALS Equipment List 2018
5 & 35 Day Report5 & 35 Day Incident Report
Add Vehicle ApplicationApplication to add a vehicle
Fee Schedule - 2018-2019Fee Schedule - Effective November 1, 2018
Medical Director AgreementThe medical director agreement
Drop Vehicle ApplicationDrop Vehicle Application
Commercial Ground Service Licensing ApplicationCommercial Amb. Services License Application
Commercial Officers FormForm to list all of the Commercial Service Offers