NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Emergency Medical Services
Name of Agency
Name
DOH Agency ID Number:
DBA or Assumed Name (if any)
Physical Location / Address
City State Zip Code
Service Mailing Address
City State Zip Code
County
Phone Numbers
Business Phone Fax
FEIN***
Federal Employer ID Number
Emergency Phone Numbers Direct 10 Digit Number: Check if Called Through 911
Chief Operations Officer
Name Title
Day Phone Night Phone Home Phone Cell / Pager
Email Address
Dispatching Agency
Name
Check if Self Dispatched
Dispatch Communications Radio Frequency: FCC Call Sign:
Number of Certified Providers CFR: EMT: AEMT**: Critical Care**: Paramedic**:
Number of Response Vehicles Ambulance: EASV: ALS-FR:
Service Medical Director
Name NYS License #
REMAC Authorized Level of Care EMT AEMT EMT-CC EMT-P
(Check Highest Level *)
Number of EMS Calls Annually Total Number of Calls Dispatched: Number of Emergency Calls:
Person Completing This Form
Name (Please Print Legibly) Title
Sigature Date
* NOTE: ALS levels of care require written REMAC approval. Contact your REMSCO for ALS credentialing criteria.
** NOTE: ALS Certified personnel may ONLY provide care at BLS level when responding with BLS authorized services.
*** NOTE: Federal Employer ID # must be provided for any service intending to apply for EMS training reimbursement from NYSDOH or
that receives provider reimbursement / funding from Medicare or Medicaid.
REMINDER: Please submit an update for your agency if your location, mailing address, chief of operations or
contact information / phone numbers change. – THANK YOU! –
Certified Services: Please complete form with your information and send it to the address below. If you have questions about filling out this form,
please contact the DOH Bureau of EMS, Operations Section for assistance at 518-402-0996
Return Completed Form to: Attn: Agency Update – OPS
NYS DOH Bureau of EMS
875 Central Avenue
Albany, New York 12206-1388
Fax: (518)402-0985
Do Not Write or Mark in Box Below
Update Received: Data Entry: Entry By: Notes:
DOH-2936 (1/14)
Certified EMS Agency
Information Update Form
