Fillable Application for EMS Operating Certificate (New York State)

Fill Online, Printable, Fillable, Blank Application for EMS Operating Certificate (New York State) Form

Use Fill to complete blank online NEW YORK STATE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Application for EMS Operating Certificate (New York State)

On average this form takes 54 minutes to complete

The Application for EMS Operating Certificate (New York State) form is 3 pages long and contains:

  • 0 signatures
  • 4 check-boxes
  • 214 other fields

Country of origin: US
File type: PDF

Free fillable forms for New York State

BROWSE NEW YORK STATE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Emergency Medical Services
Current Expiration Date / / Ambulance Service ALS First Response Service (non-transporting)
Name of Service Federal Employer ID No. NYS EMS Agency Code
Physical Address of Principal Business Location Street and Number
City, Town, Village State Zip Code County
Mailing Address (PO Box)
Business Phone Number Fax Number 911 Center 10 Digit Phone Number
( ) - ( ) - ( ) -
Agency E-mail Address Agency Website
Organizational Structure (check only one)
Commercial Hospital Based Independent Industrial
Fire Department Municipal/Government College (State or Private Campus/University)
Type of Ownership
Individual Corporation ( for profit not for profit) Municipal Fire Ambulance District
Partnership Municipal ( village town city county) Government ( State Federal)
Name of Individual Owner, Partners or Government/Municipal entity
If a corporation, give official corporate name. Also indicate all DBAs on file with NYS Department of State. Attach separate list if more than one DBA
on file. (initial applications must provide certified copies of all DOS filings both corporation and DBA)
Corporation Name
DBA/Assumed Name
For Profit and Not for Profit Corporations must provide names/addresses of current corporation officers
Name Home Address Home Phone
President ( ) -
Vice President ( ) -
Secretary ( ) -
Treasurer ( ) -
Chief Operating Officer (Captain, Operations Manager)
Name Title Day Phone Night Phone
( ) - ( ) -
Tax District
Is this organization funded by a tax district? Yes No Name of District
Name of Operator (if different from owner) Business Phone
( ) -
Address City State Zip
Highest Level of Care Currently Authorized by REMAC (check only one) EMT AEMT Critical Care Paramedic
Agency Participates in CME Program Yes No
Billing for Service Yes No
If yes , Name of Service Bureau Service Bureau Number (if not agency) Medicaid Number
Application for EMS Operating Certificate
DOH-206 (4/14) p 1 of 2
Service Physician Medical Director (please list all others on separate sheet)
Address Phone NYS Physician License Number
( ) -
List the address of each location where any certified EMS response vehicle is garaged if not the same as your principal location.
Provide list if more than 3
Location 1 Number of vehicles assigned
Location 2 Number of vehicles assigned
Location 3 Number of vehicles assigned
Total Number of Vehicles operated by certificate holder
Ambulances
EASV’s (ambulance service only)
First Response (ALSFR)
Description of operating territory boundaries etc.:
Total Employees/Members:
Number Volunteer
Number Paid (on payroll)
Provide number of individuals currently certified at each level
CFR
EMT
AEMT
Critical Care
Paramedic
Communications/Dispatch Information
Principal Dispatch Method:
Two-way
Cellular Phone
Pager
Other
Frequency on which you are dispatched
MHz
Agency that dispatches your service Local 911/PSAP
Self
Identify radio systems for hospital calling/medical direction
VHF
UHF
Cellular
Other
UHF MED 1-8 capacity
Yes
No Do your vehicles have Cellular Phones
Yes
No
155.340 capability
Yes
No Call sign if service has FCC License
Attachments Required • Affirmation of Compliance (DOH-1881, Affirmation Side 1 MUST BE NOTARIZED)
• List of all vehicle operated by the service (DOH-1881 Affirmation side 2)
• List of all agency personnel –Use DOH-2828
• List of all owners with 10% of more share of ownership
• Map of current operating territory
Agency Certification I have received and read and understand the contents of the following documents and will comply with all requirements:
• Article 30/30A, NYS Public Health Law
• Part 800, 10NYCRR, State EMS Code
• Applicable DOH EMS Policy Statements and SEMAC Advisories
In addition, I certify that all the information contained in this application is true and correct, and that neither the corporation nor any of the
owners, principals, or stockholders have been convicted of Medicaid or Medicare fraud, and I understand that under Section 3012(a) or PHL
Article 30 that the ambulance service or ALSFR service certificate for this agency may be revoked, suspended, limited or annulled if this
application includes willful misrepresentation.
Name of Owner, CEO or COO Title
Signature Date
Notary Public affirmation and acknowledgement
DOH-206 (4/14) p 2 of 2
For DOH Use Only
Date Application Received
New Expiration Date
BEMS review and approval
Date
ADDENDUM TO DOH-206 FORM
Please use this form to list additional Corporate Officers not listed on DOH-206 Form.
See General Instructions for Renewal Form Completion.
Officer Title and Name Home Address Home Phone Number
DOH-206 (4/14) Addendum
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Application for EMS Operating Certificate (New York State)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 15 March 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document