EMS Provider 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.

Preliminary EMS Report - Short Form 2012MIEMSS Short Form Patient Information Sheet

Commercial Ambulance Applications & Forms

Neonatal Equipment ListNeonatal Equipment List
Personal Injury Report FormThe Personal Injury Report Form
Personnel ListThe personnel list
Neonatal Application The neonatal application
Fee Schedule - September 2018Fee Schedule - Effective September 1, 2018
Fee WorksheetVehicle Fee Worksheet
Medical Director AgreementThe medical director agreement
Quality Assurance Officer Designation FormQuality Assurance Officer Designation Form
Transfer Vehicle License ApplicationApplication to transfer vehicle license
Upgrade/Downgrade Vehicle ApplicationApplication to upgrade/downgrade vehicle license
Vehicle Collision & Personal Injury Report FormThe Vehicle Collision & Personal Injury Rpt For
Temporary Upgrade Request FormForm to request temporary upgrade
Service ApplicationCommercial Amb. Services License Application
Specialty Care ApplicationSpecialty care application
Specialty Care Equipment ListSpecialty Care Equipment List
Fee Schedule - October 2018Fee Schedule - Effective October 1, 2018
Authorized Signatures FormForm to authorize signatures
BLS Equipment ListMIEMSS/SOCLAR BLS Equipment List 2018
Commercial Air Ambulance Service Licensing ApplicationCommercial Air Amb. Service Licensing Applica
ALS Equipment ListMIEMSS/SOCALR ALS Equipment List 2018
5 & 35 Day Report5 & 35 Day Incident Report
Add Vehicle ApplicationApplication to add a vehicle
Affiliation Verification FormForm to change or add an affiliation
Drop Vehicle ApplicationDrop Vehicle Application
Fee Schedule - June 2018Fee Schedule - Effective June 1, 2018
Fee Schedule - March 2018Fee Schedule - Effective March 1, 2018
Fee Schedule - May 2018Fee Schedule - Effective May 1, 2018
Fee Schedule - July 2018Fee Schedule - Effective July 1, 2018
Fee ScheduleFiscal year 2018 price list for Commercial Amb.
Fee Schedule - April 2018Fee Schedule - Effective April 1, 2018
Fee Schedule - August 2018Fee Schedule - Effective August 1, 2018