EMS Clinician 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.

 TitleCategory
Preliminary EMS Report - Short FormMIEMSS Short Form Patient Information Sheet

Commercial Ambulance Applications & Forms

Service Applications

 TitleDescription
Optional/Pilot Program ApplicationApplication for the participation in the Optional/Pilot Program. (Updated 1/2022)
Commercial Ground Service Licensing ApplicationApplication for new commercial ground ambulance service.
Neonatal Service ApplicationApplication for a commercial ambulance service to become Neonatal licensed.
Specialty Care Transport ApplicationApplication for a commercial ambulance service to become Specialty Care licensed.

Equipment Checklists

 TitleDescription
ALS Equipment ListMIEMSS/SOCALR ALS Equipment List July 1, 2022 – June 30, 2023
BLS Equipment ListMIEMSS/SOCALR BLS Equipment List July 1, 2022 – June 30, 2023
Neonatal Equipment ListMIEMSS/SOCALR NEO Equipment List July 1, 2022 – June 30, 2023
Specialty Care Transport Equipment ListMIEMSS/SOCALR SCT Equipment List July 1, 2022 – June 30, 2023

Personnel Forms

 TitleDescription
5 & 35 Day Report (MS Word)
  • Medical Case Review
  • Patient Care Quality Assurance Incident Report (PCQA-IR)
  • 5-Day and 35-Day incident report.
5 & 35 Day Report (PDF)
  • Medical Case Review
  • Patient Care Quality Assurance Incident Report (PCQA-IR)
  • 5-Day and 35-Day incident report.
Commercial Officer Form Form to list all of the Officers of a commercial ambulance service.
Medical Director Agreement FormMedical Director agreement for a commercial ambulance service.
Quality Assurance Officer Designation FormForm to designate a QA Officer.
SCT Coordinator Designation FormForm to designate a service SCT Coordinator

Fees

 TitleDescription
Fee ScheduleSchedule of fees for July 1, 2022 – June 30, 2023.

Vehicles Applications/Forms

 TitleDescription
Add Vehicle Application Application to add a vehicle to a commercial ambulance service’s fleet.
Drop Vehicle ApplicationApplication to remove a vehicle to a commercial ambulance service’s fleet.
Temporary Downgrade Request FormForm to request a temporary downgrade of a vehicle’s license level.
Temporary Upgrade Request FormForm to request a temporary upgrade of a vehicle’s license level.
Transfer Vehicle Application Application to transfer a vehicle’s license to another vehicle in a service’s fleet.
Upgrade/Downgrade Vehicle Application Application to request a permanent upgrade or downgrade of a vehicle’s license level.
Vehicle Collision & Personal Injury ReportForm to report a vehicle collision or personal injury.

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