Fillable Community Ems Program Application Updated (Commonwealth of Massachusetts)

Fill Online, Printable, Fillable, Blank Community Ems Program Application Updated (Commonwealth of Massachusetts) Form

Use Fill to complete blank online COMMONWEALTH OF MASSACHUSETTS (MA) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Community Ems Program Application Updated (Commonwealth of Massachusetts)

On average this form takes 20 minutes to complete

The Community Ems Program Application Updated (Commonwealth of Massachusetts) form is 8 pages long and contains:

  • 6 signatures
  • 9 check-boxes
  • 50 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) 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
 
1
CHARLES D. BAKER
Governor
KARYN E. POLITO
Lieutenant Governor
MARYLOU SUDDERS
Secretary
MONICA BHAREL, MD,
MPH Commissioner
Tel: 617-624-6000
www.mass.gov/dph
The Commonwealth of Massachusetts
Executive Office of Health and Human Services
Department of Public Health
Bureau of Health Care Safety and Quality
Office of Emergency Medical Services
Mobile Integrated Health Care Program
67 Forest Street, Marlborough MA 01752
Application for Approval
Community EMS Program
INSTRUCTIONS
This application form is to be completed by a local public health authority in partnership
with the primary ambulance service in the relevant local jurisdiction that wishes to apply
for a Certificate of Approval to operate a Community EMS Program. The application is
intended for proposed service(s) of the applicant, in the jurisdiction over which the local
public health authority has authority and in which the partnered ambulance service is
the primary ambulance service. The application must be received by the Department of
Public Health (Department) at least 30 calendar days prior to anticipated
commencement of Community EMS Program operations.
Unless indicated otherwise, all responses must be submitted in the format
specified. Handwritten responses or attachments will not be accepted.
Attachments should be labeled or marked so as to identify the question to which
they relate.
REVIEW
Applications are reviewed in the order they are received.
After a completed application is received by the Department, the Department will review
the information and will contact the applicant if clarifications or additional information for
the submitted application materials are needed.
If the applicant does not receive a response from the Department within 30
calendar days of its receipt of the completed application, the applicant may
commence operations.
2
REGULATIONS
For complete information regarding approval of a Community EMS Program, please
refer to 105 CMR 173.000 and associated sub-regulatory guidance. It is
the applicant’s responsibility to ensure that all responses are consistent
with the requirements of 105 CMR 173.000 and associated sub-regulatory
guidance, and any requirements specified by the Department, as applicable.
QUESTIONS
If additional information is needed regarding the Community EMS Program
application process, please contact the MIH Program at
(617)753-8484 or MIH@state.ma.us.
APPLICATION ATTACHMENT CHECKLIST
This application and all required attachments.
Letter of support from the authorized signatory of the local jurisdiction, if
signature on this application could not be completed. Submission should be on
official letterhead of jurisdiction.
For anyone who wants to propose adding a service to the Defined List of
Community EMS Program Services, a Petition for Addition of, or Exclusion
from, the Defined List of Community EMS Program Services form must be
completed. Applicants may not apply for a Community EMS program that
intends to provide services outside of the current Defined List of Community
EMS Program Services without a petition. The timeframe for consideration
of petitions by DPH is not limited to 30 calendar days.
Application Resubmission. If this is a Re-submission, please include your
previous application number in the box on the below. Your application number or
ID is provided on the last page of the previous application if it was saved
Previous Application Number:
To submit this application and all required supporting documentation, please fax the
documents to 617-887-8751. Applicants must label all supporting documents
with the 14-digit application number found on the last page of this application.
Please attach all required supporting documents.
Ambulance Information
For each local jurisdiction covered by the proposed program, the primary ambulance
service must be included. Please list below the ambulance license number, contact
name and title, telephone number, and email address as applicable. You may enter
multiple values as applicable in the space provided below.
Primary Ambulance
Service Name
Applicable Local
Jurisdiction(s)
Ambulance License
Number
Ambulance Contact
Name
Title
Telephone Number
Email Address
Total EMS Personnel
FTEs in Proposed
Program
Total Paramedic FTEs
in Proposed Program
Operationally Affiliated
Health Care
Organizations
Program Funding
Proposed Program
Start Date
1. APPLICANT INFORMATION
Date:
Agency funds/tax revenue Grant support 3
rd
party payers
Other (describe):
3
Affiliate Hospital Medical Director Information
Name of Primary Ambulance Service’s
Affiliated Hospital Medical Director
Title
Telephone Number
Email Address
Local Public Health Authority (LPHA) Information
Name of Local Public Health Authority
Address of Local Public Health Authority
Street
City State Zip Code
Local Public Health Authority Contact
Name
Title
Telephone Number
Email Address
Name of LPHA Authorized Signatory
Signature of LPHA Authorized Signatory
Date of Signature
Please refer to the instructions document on how to create an e-signature located at:
*
*
www.mass.gov/MIH
4
click to sign
signature
click to edit
TEST
5
________________
Date Signed
___________________________________________________________________________
Print Name Local Jurisdiction Authorized Signatory
___________________________________________________________________________
Title of Local Jurisdiction Authorized Signatory
____________________________________
_______________
Signature of Local Public Health Authority Authorized Signatory Date Signed
___________________________________________________________________________
Print Name Local Public Health Authority Authorized Signatory
___________________________________________________________________________
Title of Local Public Health Authority Authorized Signatory
___________________________________
Signature of Affiliated Hospital Medical Director
_______________
Date Signed
___________________________________________________________________________
Print Name of Affiliated Hospital Medical Director
___________________________________________________________________________
Title of Affiliated Hospital Medical Director
Attestation:
In accordance with 105 CMR 173.000, the undersigned hereby applies for designation to
establish a Community EMS Program as set forth under provisions of 105 CMR 173.000.
The undersigned representative(s) of the provider hereby attest that, (1) the information
provided in and submitted with this document is accurate and correct to the best of my
knowledge; (2) the failure to file a complete and accurate application for approval or
renewal may constitute grounds for denial or revocation of approval; and, (3) pursuant
to the applicant’s responsibility as an approved Community EMS Program to comply
with 105 CMR 173.000, the applicant understands and acknowledges the regulatory
requirements of 105 CMR 173.000 and associated guidance documents, and is in
compliance with the regulatory requirements of 105 CMR 173.000, and can provide
verification of compliance upon request.
Attestation for Local Jurisdiction only. Attach a letter of support from Local Jurisdiction
authorized signatory if signature cannot be obtained.
I am duly authorized to approve this application on behalf of the City/Town of:
_____________________________________
Signature of Local Jurisdiction Authorized Signatory
_________________
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
6
2. PROGRAM OVERVIEW
a. Please attach a description of the program and proposed services, including
addressing:
i. The target population;
ii. The location of services;
iii. The timing (beginning and end dates, and any seasonality) proposed for
the program; and
iv. All operational partnerships involved
3. SERVICES PROVIDED
a. Indicate below which of the evidence-based illness and injury prevention
services deemed high-value public health services with low risk potential to
patients your program will provide, after referring to the list of allowable
Community EMS services online. If additional space is required please attach a separate
document.
Note: Applicants may only apply to become a Community EMS program
proposing services that are
included in the Defined List of Community EMS
Program Services. For any service not contained on such list, individuals
must separately submit a Petition for Addition of, or Exclusion from, the Defined List
of Community EMS Program Services form, which includes written request
including a description of the service with appropriate s
upplemental evidence
supporting the future inclusion in the Defined List of Community EMS Program
Services. The timeframe for consideration of petitions by DPH is not limited to
30 calendar days.
7
4. ATTESTATIONS
a. I attest that the Community EMS Program will only operate and provide services
and community outreach and assistance to residents of the local jurisdiction(s) in
which the ambulance service is the primary service.
b. I attest that all EMS Personnel training and activities related to the Community
EMS Program will be approved by the local public health agency and the primary
ambulance service’s affiliate hospital medical director.
_____________________________________
_
______________
Signature of Affiliate Hospital Medical Director
Date Signed
_____________________________________________________________________
P
r
int Name of Affiliate Hospital Medical Director
_____________________________________________________________________
Title
of
A
ffiliate
H
ospital Medical Direc
tor
_____________________________________
Signature of Local Public Health Authority Authorized Signatory
______________
Date Signed
i. Ensure all EMS personnel providing services in the Community EMS Program
successfully complete additional training tailored to meet the specific needs of the
particular Community EMS Program.
ii. Review the quality of the EMS personnel’s delivery of services.
iii. Ensure EMS personnel provide services only within their scope of practice.
iv. Ensure vehicles deployed by the primary ambulance service partner are appropriate
for the clinical encounter, and that all regulatory and manufacturer requirements
specific to equipment, supplies and medications will be adhered to when responding
to a Community EMS encounter.
v. Ensure that the 911 EMS system will be activated and that the Community EMS on-
scene personnel will continue to assess and treat a patient in accordance with
clinical protocols until transfer of care to the responding ambulance s
ervice, if an
assessment in coordination with medical direction indicates to on-scene personnel
that the patient is experiencing a medical emergency.
______________________________________________________________________
Print Name of Local Public Health Authority Authorized Signatory
______________________________________________________________________
Title of Local Public Health Authority Authorized Signatory
c. I attest that the designated primary ambulance service’s affiliate hospital medical
director will:
click to sign
signature
click to edit
click to sign
signature
click to edit
8
3. To submit this application and all required supporting documentation, please
fax the documents at 617-887-8751. Applicants must label all supporting
documents with the 14-digit application number found on this page as above
(in red) once application is completed.
This document is ready to submit:
Date:
Your Application Number:
Use this number on all communications regarding this application.
Document ready for Filing
1. When document is complete click on "Document is ready to submit". This will generate
an application number, lock the responses, generate today’s date and time-stamp the
form.
2. Please keep a copy for your records by clicking on the "Save" button at the bottom of
the page.
Save
Print
Reset
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

Community Ems Program Application Updated (Commonwealth of Massachusetts)

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 26 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document