NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Emergency Medical Services and Trauma Systems
Verification of NYS Certification
EMS Identification Number
Only write your NYS EMS number in this space
First Name and M.I.
Social Security Number Month Day Year
Date of Birth
Certified Provider’s Mailing
State Zip Code Name or address change since you last became certified?:
If you require that your letter of verification be e-mailed to a different e-mail address, please provide the e-mail address to
which the letter should be sent:
(Certified Provider’s Signature)
Please print legibly in capital letters or type. Put one letter or number in each box.
A letter of verification will be e-mailed to the e-mail address from which this form is submitted.
Requests for verification of certification must be submitted using this form.
No telephone requests will be accepted. Allow 2-4 weeks for processing.
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