DOH-5136 (8/17) Page 2 of 3
The EMS Agency is required to submit PCR data to the EMS Region and NYSDOH for use in quality improvement programs. The Agency
may delegate management of its e-PCR system to a third-party; however, the Agency remains legally responsible for assuring the proper
collection, use, protection, and confidentiality of data within the e-PCR system, as well as for the timely submission of data to the
Services . . . certified pursuant to article thirty . . . shall submit detailed individual call reports. [Article 30 §3053]
Information from the prehospital care reporting system . . . shall be kept confidential and shall not be released except
to the department or pursuant to [a quality improvement program].
[Article 30 §3006(2)]
All signatories on this application:
1. Attest that their respective entities abide by all applicable Federal and State rules governing the collection, use, protection,
confidentiality, and submission of electronic patient healthcare information;
2. Agree that their respective entities will assist each other in assuring the protection and confidentiality of any data exchanged
between them; and
3. Understand that any data in the possession of their respective entities is to be used only for the lawful purposes allowed their entity.
Data Submission and Use Agreement
NYSDOH APPROVAL (Page 3 of this Application) MUST BE RECEIVED PRIOR TO GOING-LIVE WITH ANY e-PCR SYSTEM.
CONSULT THE REGIONAL EMS PROGRAM AGENCY BEFORE CHOOSING A GO-LIVE DATE.
• Approval (and thereby, any go-live date) can be affected by many factors, which the EMS Agency should considered in consultation
with the Program Agency.
• If the EMS Agency later encounters difficulties that will impact this date, the EMS Agency must contact the Program Agency
immediately to amend this application.
EMS AGENCIES CONVERTING FROM PAPER TO e-PCR: By the go-live date, the EMS Agency must go-live with the described e-PCR system;
at which time the Program Agency will no longer provide blank paper PCRs to, or accept completed paper PCRs from, the EMS Agency.
EMS AGENCIES CHANGING e-PCR SYSTEMS: By the go-live date, the EMS Agency must go-live with the new e-PCR system and discontinue
use of the previous system.
By what date is the EMS Agency planning to go-live with the new e-PCR system? ______ / ______ /______
When transferring patient care to the hospital, the EMS crew must provide the receiving hospital staff with BOTH VERBAL AND WRITTEN
REPORTS – AT THE TIME OF PATIENT TRANSFER.
Every person certified at any level pursuant to this Part or Article 30 of the Public Health Law . . . [when] responsible for
patient care shall accurately complete a prehospital care report . . . and shall provide a copy to the hospital receiving the
How will the EMS crew provide a WRITTEN REPORT to the receiving hospital AT THE TIME OF PATIENT TRANSFER?
Print e-PCR (Before Leaving Hospital) e-Mail e-PCR (Before Leaving Hospital)
Fax e-PCR (Before Leaving Hospital) Electronically Transfer e-PCR (Before Leaving Hospital)
Provide Paper Summary with Patient; Then Fax/e-Mail/e-Transfer e-PCR within _______ Hours
ontinuity of Care Agreement