Maryland Institute for Emergency Medical Services Systems

EMS Clinician Documents

EMS Clinician Forms

All EMS forms are available online at MIEMSSLicense.com, the MIEMSS Licensure System. We encourage everyone to use this web-based system, as it is the most expedient means of processing your request.

 TitleCategory
Preliminary EMS Report - Short FormMIEMSS Short Form Patient Information Sheet

Commercial Ambulance Applications & Forms

Service Applications

 TitleDescription
Commercial Ground Service Licensing ApplicationApplication for new commercial ground ambulance service.
Neonatal Service ApplicationApplication for a commercial ambulance service to become Neonatal licensed.
Optional/Pilot Program ApplicationApplication for the participation in the Optional/Pilot Program. (Updated 1/2022)
Specialty Care Transport ApplicationApplication for a commercial ambulance service to become Specialty Care licensed.

Equipment Checklists

 TitleDescription
ALS Equipment ListMIEMSS/SOCALR ALS Equipment List (Effective July 1, 2023 – June 30, 2024)
BLS Equipment ListMIEMSS/SOCALR BLS Equipment List (Effective July 1, 2023 – June 30, 2024)
Neonatal Equipment ListMIEMSS/SOCALR NEO Equipment List (Effective July 1, 2023 – June 30, 2024)
Specialty Care Transport Equipment ListMIEMSS/SOCALR SCT Equipment List (Effective July 1, 2023 – June 30, 2024)

Personnel Forms

 TitleDescription
5 & 35 Day Report (MS Word)
  • Medical Case Review
  • Patient Care Quality Assurance Incident Report (PCQA-IR)
  • 5-Day and 35-Day incident report.
5 & 35 Day Report (PDF)
  • Medical Case Review
  • Patient Care Quality Assurance Incident Report (PCQA-IR)
  • 5-Day and 35-Day incident report.
Commercial Officer Form Form to list all of the Officers of a commercial ambulance service.
Medical Director Agreement FormMedical Director agreement for a commercial ambulance service.
Non EMS licensed driver entry formForm to add Non EMS licensed driver to your approved SOCALR list
Quality Assurance Officer Designation FormForm to designate a QA Officer.
SCT Coordinator Designation FormForm to designate a service SCT Coordinator

Fees

 TitleDescription
Fee ScheduleSchedule of fees (Effective July 1, 2023 – June 30, 2024)

Vehicles Applications/Forms

 TitleDescription
Add Vehicle Application Application to add a vehicle to a commercial ambulance service’s fleet.
Drop Vehicle ApplicationApplication to remove a vehicle to a commercial ambulance service’s fleet.
Temporary Upgrade Request FormForm to request a temporary upgrade of a vehicle’s license level.
Transfer Vehicle Application Application to transfer a vehicle’s license to another vehicle in a service’s fleet.
Upgrade/Downgrade Vehicle Application Application to request a permanent upgrade or downgrade of a vehicle’s license level.
Vehicle Collision & Personal Injury ReportForm to report a vehicle collision or personal injury.

Others

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Copyright 2023 Maryland Institute for Emergency Medical Services Systems

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1-800-762-7157 or Dial 7-1-1 to place a call through Maryland Relay