medical command authorization form

_____________________________________                                                                                                 Last Name           FIRST                      MI                                                                               

ALS Service Affiliate #

Calendar Year

 

____________________________________________________________________________ Street ADDRESS ____________________________________________________________________________ City                                                               STATe                                             ZIP CODE __________________________________________________________________________    E-Mail Address

Check One:     ___ EMT-Paramedic     ___ PHRN   ___ HP Physician   ___ Other ___________________

Department EMT-P/PHRN/HP#: _______________     

Name of ALS Service ______________________  

PHRN & Physician Only

PA License #: ________________________

License Expiration Date :________________

 

 

1.  List all ambulance services with which you have had medical command authorization in the past five years.  If necessary, please use a separate sheet of paper. 

Name of Service ____________________________   Dates with Service__________________________   Service Medical Director __________________    Telephone Number __________________________  

Name of Service ____________________________   Dates with Service__________________________   Service Medical Director __________________    Telephone Number __________________________

Name of Service ____________________________   Dates with Service__________________________   Service Medical Director __________________    Telephone Number __________________________

Name of Service ____________________________   Dates with Service__________________________   Service Medical Director __________________    Telephone Number __________________________

Name of Service ____________________________   Dates with Service__________________________   Service Medical Director __________________    Telephone Number __________________________

Name of Service ____________________________   Dates with Service__________________________   Service Medical Director __________________    Telephone Number __________________________

2.  Has your medical command authorization ever been restricted?  If yes, please provide a full description of each restriction on a separate sheet of paper, including name of ALS service and ALS service medical director. 

___  YES, Restricted for Initial Precepting                      ___  YES, Restricted for Other Reason                       ___  NO 

3.  Has your medical command authorization ever been denied or withdrawn?  If yes, please provide a full description of each denial or withdrawal on a separate sheet of paper, including name of ALS service and ALS service medical director. 

___ YES ___  NO

4.  Has any disciplinary sanction been imposed against you (regardless of whether it is presently stayed pending disposition of an appeal),  or is any disciplinary charge currently pending against you?  If yes, please explain on a separate sheet of paper. 

___  YES   ___ NO

Please attach copies of the following:

___  Current BCLS Course Completion                          ___   Previous Year's Continuing Education Record ___   Pennsylvania Certification                               ___   Pennsylvania License (Physician/PHRN)        ___   Attachments for Questions 1-4 (If Applicable)
I hereby certify that the information provided in this applications is true and correct to the best of my knowledge, information, and belief.  I grant the ALS service/medical director permission to investigate all information on this application, and I grant third parties permission to release information about my professional competence to the ALS service/medical director.  I understand that if my application is approved for medical command, this authorization will be valid for the current calendar year, unless restricted or withdrawn by the ALS service medical director.  I further understand that if granedt medical command authorization, it applies only to the ALS service listed on this application and only permits practice in accordance with the Statewide and regional medical treatment protocols. 

___________________________________________           _______________________                                Signature of Applicant                                                              Date