Fillable Community Ems Program Service Petition Form Updated (Commonwealth of Massachusetts)

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Community Ems Program Service Petition Form Updated (Commonwealth of Massachusetts)

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U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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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
P
etition for Addition of, or Exclusion from, the
List of Pre-Approved Community EMS Program Services
Community EMS is a system of collaborative care in which EMS Personnel of a primary
ambulance service partner with a local public health authority to support illness or injury
prevention efforts through high-value public health services. The Department of Public Health
(Department) has defined a list of approved Community EMS Program services which programs
may apply to provide, based on the needs of the community that they serve.
Pursuant to 105 CMR 173.060(B), Community EMS Programs may also request that the
Department add to, or exclude from, the list of pre-approved services that the individual
Community EMS applicants can apply for or request an exclusion.
Please complete and submit this form to petition for the addition of (or exclusion from) the List
of Pre-Approved Community EMS Services. Please attach and submit additional documents,
program descriptions, and letters of support to support this petition
Name of Additional
(or Excluded) Service:
*If new service
proposed, description
of Proposed Service:
Supporting Evidence
* Description, at a minimum, should outline how proposed service is consistent with community
health needs, population to be served, and resource(s) that will provide service.
Please identify a point of contact for your organization.
Name:
Title:
Organization:
Phone Number:
Email:
Please email completed form and additional documentation to MIH@state.ma.us.
Questions should be directed to the MIH Program at MIH@state.ma.us or (617) 753-8484.
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Community Ems Program Service Petition Form Updated (Commonwealth of Massachusetts)

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Completed 26 July 2020

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