Get Non-transport Provider Application - Illinois Department Of Public ... - Idph State Il

This guide provides clear instructions on completing the Non-transport Provider Application for the Illinois Department of Public Health. Whether you are familiar with digital forms or new to this process, this guide aims to support you in providing the necessary information accurately and efficiently.

Follow the steps to successfully complete the application.

1. Press the ‘Get Form’ button to access and open the Non-transport Provider Application form.
2. Begin by entering the EMS system name, number, and address. Make sure to include the complete address with the city, state, and ZIP code.
3. Check the appropriate Non-transport Level of Care options, such as ALS, ILS, B/D, BLS, FRD, or CCT, depending on the services you provide.
4. In the vehicle description section, provide the type, local ID number, VIN, and level of care for each vehicle being used for non-transport services.
5. Describe the role of each vehicle in the provision of Emergency Medical Services (EMS), including the coverage area for each vehicle.
6. Outline your patient transport procedures and attach copies of any transport agreements, if applicable.
7. Explain how the vehicle(s) will communicate with the resource hospital for receiving medical direction.
8. Sign and provide your title and the date on the form to indicate your agreement to follow all EMS system policies and procedures.
9. After filling out the form, save any changes and consider downloading, printing, or sharing the completed application for your records.

Complete your Non-transport Provider Application online today to ensure timely processing.