Get Idph Sysmod Form - Samicems.org - Jch

Filling out the IDPH SYSMOD FORM is an important process for requesting modifications to an approved emergency medical services system plan. This guide provides a comprehensive overview of each section of the form, helping users navigate it seamlessly.

Follow the steps to successfully complete the IDPH SYSMOD FORM.

1. Press the ‘Get Form’ button to access the document and open it for editing.
2. Begin by filling in the EMS/MD name and the resource hospital name in the designated fields.
3. Next, enter the EMS system number, address, city, state, and ZIP code accurately in their respective sections.
4. Provide the provider name, the provider's city and state, and obtain the necessary signatures for both the provider and agent, along with the license number.
5. Fill in the last four VIN numbers and indicate the current and requested levels of care.
6. Check the appropriate items for your request—whether you are requesting an upgrade, downgrade, modifications in access and dispatch procedures, or additional vehicles.
7. For modifications to the response area, attach a separate sheet with the necessary changes, including a map and descriptions.
8. Once all sections are filled out correctly, ensure all signatures are obtained before preparing two copies of the complete application.
9. Submit the completed form to the regional EMS coordinator, ensuring that the application is three-hole punched as specified.
10. After submission, save any changes, and if needed, download or print a copy for your records.

Complete the IDPH SYSMOD FORM online today to ensure your EMS system plan is up to date.