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

Quality Assurance Officer Designation FormQuality Assurance Officer Designation Form
Specialty Care ApplicationSpecialty care application
Personnel ListThe personnel list
Neonatal Equipment ListNeonatal Equipment List
Personal Injury Report FormThe Personal Injury Report Form
Specialty Care Equipment ListSpecialty Care Equipment List
Upgrade/Downgrade Vehicle ApplicationApplication to upgrade/downgrade vehicle license
Vehicle Collision & Personal Injury Report FormThe Vehicle Collision & Personal Injury Rpt For
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
ALS Equipment ListMIEMSS/SOCALR ALS Equipment List 2018
Authorized Signatures FormForm to authorize signatures
Affiliation Verification FormForm to change or add an affiliation
5 & 35 Day Report5 & 35 Day Incident Report
Add Vehicle ApplicationApplication to add a vehicle
BLS Equipment ListMIEMSS/SOCLAR BLS Equipment List 2018
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