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EMS Agency Renewal Submission
Welcome to the New York State Department of Health Bureau of Emergency Medical Service EMS agency renewal portal.
All renewal applications are due no less than 30 days prior to the expiration date of the agency’s operating certificate. Ensure that all of the required documents are completed and uploaded in the appropriate section.
Please make sure that all corporate officers, including volunteer officers, Home addresses and telephone numbers are included.
Review PHL Article 30/30A to ensure compliance with all requirements.
https://www.health.ny.gov/professionals/ems/art30.htm
Ensure your agency is compliant with NCRR Title 10 Part 800:
https://regs.health.ny.gov/volume-e-title-10/200443669/part-800-emergency-medical-services
To review current BEMS Policy Statements.
https://www.health.ny.gov/professionals/ems/policy/policy.htm
Should you have any questions please feel free to contact your Regional Representative:
https://www.health.ny.gov/professionals/ems/chart.htm
Submission Type
Agency Renewal
Agency Update Only
Name of Service
Agency Code
Name of Contact Person
Full Name
Email
Phone
Medical Director Information
Full Name
Email
Phone
NYS DOH EMS Region
- Select -
Central NY (Syracuse Regional Office)
Capital (Central Office)
Metropolitan (MARO)
Western Region(Buffalo and Rochester Regional Office)
Please Select Your Region
- Select -
Adirondack-Appalachian (Delaware, Fulton, Hamilton, Montgomery, Otsego, Schoharie)
Big Lakes (Genesee, Niagara, Orleans)
Central New York (Cayuga, Cortland, Onondaga, Oswego, Tompkins)
Finger Lakes (Ontario, Seneca, Wayne, Yates)
Hudson-Mohawk (Albany, Columbia, Greene, Rensselaer, Saratoga, Schenectady)
Hudson Valley (Dutchess, Orange, Putnam, Rockland, Sullivan, Ulster)
Mid-State (Herkimer, Madison, Oneida)
Monroe- Livingston (Livingston, Monroe)
Mountain Lakes (Clinton, Essex, Franklin, Warren, Washington)
Nassau (Nassau)
New York City (Bronx, Kings, New York, Queens, Richmond)
North Country (Jefferson, Lewis, St. Lawrence)
Southern Tier (Chemung, Schuyler, Steuben)
Southwestern (Allegany, Cattaraugus, Chautauqua)
Suffolk (Suffolk)
Susquehanna (Broome, Chenango, Tioga)
Westchester (Westchester)
Wyoming-Erie (Erie, Wyoming)
Level of Care
- Select -
CFR
EMT-B
AEMT
AEMT-CC
EMT-P
Select Your Agency Type
- Select -
Certified Ambulance
Certified Advanced Life Support First Response (ALSFR)
Registered Basic Life Support First Response
Please submit an updated DOH-5136 to your Regional Program Agency, completed within the last 60 days.
DOH-206 Application for EMS Operating Certificate
Upload
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
DOH-206 Addendum (If Applicable)
Upload
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
DOH-1881 Affirmation of Compliance
Upload
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
DOH-2828 EMS Agency Personnel Roster
Upload
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
DOH-4362 Medical Director Affirmation Form
Upload
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
DOH-5131 Funding Document for EMS Agencies
Upload
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
Territory Map
Upload
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
Does your agency conduct Blood Glucose (BG) testing on patients?
Yes
No
CLIA License
Upload
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
Regional Emergency Medical Advisory Committee (REMAC) approval letter if your agency provides Advanced Life Support (ALS) level of care AND has changed its level of care since the last renewal
Upload
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
Provide copies of any new assumed name (DBA) filings if it is a corporation and has added a new assumed business name since last filing. List ALL assumed names currently in use by your agency.
Upload
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
Listing of additional garaging locations of certified vehicles (ambulance or EASV) if more than three locations
Upload
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
Upload a copy of your current agency Policies and Procedures that cover Part 800.21(p) 1-15.
The links can be found here:
https://regs.health.ny.gov/content/section-80021-general-requirements
And:
https://apps.health.ny.gov/pubpal/builder/survey/ems-policies-that-are-required
Upload
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
Please submit an updated DOH-5136 to your Regional Program Agency, completed within the last 60 days.
DOH-5127 BLFR Agency Information Application/Update Form
Upload
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
DOH-2828 EMS Agency Personnel Roster
Upload
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
DOH-4362 Medical Director Affirmation Form
Upload
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
DOH-4135 Notice of Intent to Provide PAD
Upload
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
Does your agency do blood glucometry?
Yes
No
CLIA License
Upload
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
Name of Service
Agency Code
Name of Contact Person
Full Name
Email
Phone
Medical Director Information
Full Name
Email
Phone
NYS DOH EMS Region
- Select -
Central NY (Syracuse Regional Office)
Capital (Central Office)
Metropolitan (MARO)
Western Region(Buffalo and Rochester Regional Office)
Level of Care
- Select -
CFR
EMT-B
AEMT
AEMT-CC
EMT-P
Select Your Agency Type
- Select -
Certified Ambulance
Certified Advanced Life Support First Response (ALSFR)
Registered Basic Life Support First Response
Please submit an updated DOH-5136 to your Regional Program Agency, completed within the last 60 days.
DOH-5127 BLSFR Agency Information Application/Update Form
Upload
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
DOH-2828 EMS Agency Personnel Roster
Upload
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
Please submit an updated DOH-5136 to your Regional Program Agency, completed within the last 60 days.
DOH-2936 Certified EMS Agency Information Update Form
Upload
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
DOH-2828 EMS Agency Personnel Roster
Upload
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
Submit