Service Provider Certifications, Forms and Information

 

If you have questions regarding rules, equipment, or standards while filling out the applications please refer to the Title 836 rules found at: http://www.in.gov/dhs/3531.htm
    836 Rule 1 – Information for all Providers, & BLS equipment list
    836 Rule 2 – Additional Information for ALS Providers, Supervising Hospitals, & ALS
    Equipment list
    836 Rule 3- Air Ambulance Providers (fixed & rotor wing) 

Emergency Vehicle Equipment Checklist-General
This checklist includes all of the mandated equipment to be carried on BLS and ALS vehicles. Please have ready only the equipment pertaining to your level of service.

Rescue Squad

    Applications
        Initial Application
        Renewal Application

    Information
        Rescue Squad requirements & equipment list

 

BLS Non-transport Provider

    Applications
        Initial - BLS Service Provider Application
        Renewal Application 
        Staff roster  (also needs to be signed by Medical Director)

    Medical Director Approval Form 
        EMT-B (BLS) - EMT-B/A (BLS/ALS)

    Information
        04 BLS Non-transport rules 
        Non-transport equipment list   
        BLS Non-Transport Equipment List

 

BLS Ambulance Provider

    Applications
        Initial - BLS Service Provider Application (new or upgrading service)
        Renewal Application
        Staff Roster (also needs to be signed by Medical Director)

    Medical Director Approval Form
        EMT-B (BLS) - EMT-B/A (BLS/ALS)

 

ALS Provider - Transport & Non-transport

    Applications
        Initial - ALS Service Provider Application (new or upgrading service)
        Renewal Application 
        Staff roster (also needs to be signed by Medical Director)

    Medical Director Approval Form 
        BLS/ALS 

    Information
        ALS Non-transport Equipment List

 

Air Ambulance Provider

    Applications
        Inital & Renewal Application
        Aircraft Application for Certification
        Staff roster (also needs to be signed by Medical Director)

    Medical Director Approval Form
       BLS/ALS 

    Information
        Air Ambulance Equipment List

 

Supervising Hospital

   Applications
        Inital & Renewal Application
        Staff roster (also needs to be signed by Medical Director)

    Note: On Section E 'approval of medical staff' means the CMO or Chief of Staff,
    NOT the service or ED Medical Director. 

 

Vehicle Certification & other forms

    New or Replacement Vehicle Application
    Vehicle Proof of Insurance Form 
    Vehicle Accident Reporting Form

Other Provider Forms

    Blood & Body Fluid Exposure
    Pre-hospital DNR
    EMS Incident/Investigation Form

    Physician Orders for Scope of Treatment (POST) guidance