CME Registration, Communication, and Audit Portal

Agency Contact

Agency Name

Agency Number

First Name

Last Name

Email

Phone Number

Medical Director Information

Medical Director First Name

Medical Director Last Name

Email

Phone Number

Document(s)

DOH-4227 Agency Registration Form

Upload requirements

Agency Plan & Additional Documents

Upload requirements

Agency Contact

Agency Name

Agency Number

First Name

Last Name

Email

Phone Number

Medical Director Information

Medical Director First Name

Medical Director Last Name

Email

Phone Number

Updated Document(s)

Updated DOH-4227 Registration Form

Upload requirements

Updated Agency Plan

Upload requirements

Updated MOU

Upload requirements

Submitting Individual Contact Information

Full Name

Email

Phone

Provider Contact Information

Provider Full Name

Provider EMT Number

Email

Phone

Agency Name

Agency Code

Submission Type

SID # Being Audited

Please submit all relevant materials, including but not limited to certificates, transcripts, sign in/out sheets, skill sheets:

Upload requirements