Region Information

Entity Submitting

REMSCO

REMAC

Program Agency

Region Representative Submitting

Name

Email

Phone

NYS DOH EMS Council

- Select -Adirondack-Appalachian REMSCOBig Lakes Regional EMS CouncilCentral New York Regional EMS CouncilFinger Lakes Regional EMS CouncilHudson-Mohawk Regional EMS CouncilHudson Valley Regional EMS CouncilMid-State Regional EMS CouncilMonroe-Livingston Reg EMS CouncilMountain Lakes Regional EMS CouncilNassau Regional EMS CouncilNorth Country Regional EMS CouncilRegional EMS Council of New York CitySouthern Tier Regional EMS CouncilSouthwestern Regional EMS CouncilSuffolk Regional EMS CouncilSusquehanna Regional EMS CouncilWestchester Regional EMS CouncilWyoming-Erie Regional EMS Council

Councils are listed here: https://www.health.ny.gov/professionals/ems/regional.htm

Agency Information

Agency/Entity Type

Certified Ambulance

Advanced Life Support First Response

Air Medical

Basic Life Support First Response

Public Access Defibrillation Only

Agency/Entity Name

Agency Code

County

- Select -AlbanyAlleganyBronxBroomeCattaraugusCayugaChautauquaChemungChenangoClintonColumbiaCortlandDelawareDutchessErieEssexFranklinFultonGeneseeGreeneHamiltonHerkimerJeffersonKingsLewisLivingstonMadisonMonroeMontgomeryNassauNew YorkNiagaraOneidaOnondagaOntarioOrangeOrleansOswegoOtsegoPutnamQueensRensselaerRichmondRocklandSt. LawrenceSaratogaSchenectadySchoharieSchuylerSenecaSteubenSuffolkSullivanTiogaTompkinsUlsterWarrenWashingtonWayneWestchesterWyomingYates

Submission Type

Medical Director Change

Modality/Adjunct Update

PAD NOI

Statutory Actions - S3008 & S3010

Mutual Aid Plans

Modality Being Added

BLS Supraglottic Airway

BLS CPAP

BLS Syringe Epinephrine

BLS Ipratropium

BLS 12 Lead

Rapid Sequence Intubation

DOH-4362 Medical Director Affirmation Form

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Form is located here: https://www.health.ny.gov/forms/doh-4362.pdf
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• 100 MB limit.
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Original Submission ID (If initial submission came through DOH portal)

Please upload a letter on letterhead indicating the result of the regional review

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Please upload any documentation provided by the agency

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• Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.

Public Access Defibrillation

DOH-4135 Notice of Intent to Provide PAD

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Collaborative Agreement

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Statutory Actions S3008 & S3010

Action Type

3008 1-5

3010

Submission For:

Request for Fitness and Competency

Voting Results

Stenographic Minutes

Date Application Received by the REMSCO

Date Application Deemed Complete by the REMSCO

Date of Scheduled Public Hearing

Date of Scheduled Council Meeting with Vote

Date DOH-3778(s) and complete application submitted to the Division via Health Commerce System Secure File Transfer

Date Vote Occured

Please upload a copy of the voting results

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• 100 MB limit.
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Please upload a copy of the stenographic minutes from the meeting

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• One file only.
• 100 MB limit.
• Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

Mutual Aid Plans

Please upload a copy of the Mutual Aid Plan

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• One file only.
• 100 MB limit.
• Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

Participating Agencies

Re-order	Agency Code	Agency Name	Weight	Operations
	Agency Code	Agency Name	Item weight	Add new item after item 1 Remove item 1

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Add more items more items

Date plan was approved by County Coordinator

Date plan was submitted to the REMSCO

Date plan was approved by the REMSCO

Notes/Comments

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