Doh-4362 medical director verification

MEDICAL DIRECTOR VERIFICATION
Notice to Service:
Please identify the physician providing Quality Assurance oversight to your individual service. If your service provides Defibrillation, Epi-Pen,, Blood Glucometry, Albuterol or Advance Life Support (ALS),
you must have specific approval from your Regional EMS Council’s Medical Advisory Committee (REMAC)
and oversight by a NY state licensed physician. If you change your level of care to a higher ALS level, you
must provide the NYS DOH Bureau of EMS a copy of your REMAC’s written approval notice.
If your service wishes to change to a lower level of care, provide written notice of the change and the
level of care to be provided, and the effective date of implementation, to your REMAC with a copy to the NYSDOH Bureau of EMS.
If your service has more than one Service Medical Director, please use copies of this verification and indicate which of your operations or REMAC approvals apply to the oversight provided by each physician.
Please send this form to your DOH EMS Area Office for filing with your service records.
___________________________________________________________________________________
Check all special regional approvals and the single highest level of care applicable to your service: (Epi / Albuterol / Blood Glucometry per regional protocol) R AEMT– Paramedic R AEMT– Critical Care R AEMT– Intermediate R Controlled Substances Level of Care Please Type or Print Legibly:
Name of EMS Service: __________________________________________________________ Agency Code Number: _____________ Service Type: R Amb R ALSFR R BLSFR Name of Service CEO:___________________________________________________________ Name of Service Medical Director: _________________________________________________ NYS Physician’s License Number: _________________________________________________ Ambulance/ALSFR Service Controlled Substance License # if Applicable: 03C-____________
Ambulance/ALSFR Service Controlled Substance License Expiration Date: ________________ ______________________________________________________________________________________
Medical Director Affirmation of Compliance: I affirm that I am the Physician Medical Director for the above listed EMS service. I am responsible for oversight of the pre-hospital Quality Assurance/Quality Improvement program forthis service. This includes medical oversight on a regular and on-going basis, in-service training andreview of service policies that are directly related to medical care. I am familiar with applicable State and Regional Emergency Medical Advisory Committee treatment protocols, policies and applicable state regulations concerning the level of care providedby this service. If the service I provide oversight to is not certified and provides AED level care, the service has filed a Notice of Intent to Provide Public Access Defibrillation (DOH-4135) and a completedCollaborative Agreement with its Regional EMS Council. Signature – Service Medical Director: __________________________________________________________ Date of Signature: __________________________________________________________________________

Source: http://mountainlakesems.org/assets/pdf_files/Medical_Director_Verification_Form.pdf