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.

	Title	Category
	Preliminary EMS Report - Short Form	MIEMSS Short Form Patient Information Sheet

Commercial Ambulance Applications & Forms

Service Applications

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

Equipment Checklists

	Title	Description
	ALS Equipment List	MIEMSS/SOCALR ALS Equipment List (Effective July 1, 2024 – June 30, 2025)
	BLS Equipment List	MIEMSS/SOCALR BLS Equipment List (Effective July 1, 2024 – June 30, 2025)
	Neonatal Equipment List	MIEMSS/SOCALR NEO Equipment List (Effective July 1, 2024 – June 30, 2025)
	Specialty Care Transport Equipment List	MIEMSS/SOCALR SCT Equipment List (Effective July 1, 2024 – June 30, 2025)

Personnel Forms

	Title	Description
	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 Form	Medical Director agreement for a commercial ambulance service.
	Medical Review Committee Membership Form	Form to submit Medical Review Committee Membership
	Non EMS licensed driver entry form	Form to add Non EMS licensed driver to your approved SOCALR list
	Quality Assurance Officer Designation Form	Form to designate a QA Officer.
	SCT Coordinator Designation Form	Form to designate a service SCT Coordinator

Fees

	Title	Description
	Fee Schedule	Schedule of fees (Effective July 1, 2023 – June 30, 2024)

Vehicles Applications/Forms

	Title	Description
	Add Vehicle Application	Application to add a vehicle to a commercial ambulance service’s fleet.
	Drop Vehicle Application	Application to remove a vehicle to a commercial ambulance service’s fleet.
	Temporary Downgrade Request Form	Form to request a temporary downgrade of a vehicle’s license level.
	Temporary Upgrade Request Form	Form 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 Report	Form to report a vehicle collision or personal injury.

Others

Maryland Medical Orders for Life Sustaining Treatment (MOLST)
Maryland Medical Orders for Life Sustaining Treatment (MOLST)
MD Facility AED Report Form for Cardiac Arrests
MD Facility AED Report Form for Cardiac Arrests
Proposed Protocol Submission Request Policy and Template
Proposed Protocol Submission Request Policy and Template

Resources

EMS Documents & Forms

Clinician Login Assistance

eMEDS Resource Page

Quality Management Toolbox

Active Assailant Guidance

Maryland Active Assailant Guidance ...
Maryland Active Assailant Guidance