Get (ems) Systems Ambulance Staffing Waiver Request Application - Idph State Il

Filling out the (EMS) Systems Ambulance Staffing Waiver Request Application is essential for providers seeking a staffing waiver for their ambulance services in Illinois. This guide provides a clear, step-by-step approach to assist you in completing the form accurately and efficiently.

Follow the steps to complete the application successfully.

1. Click the ‘Get Form’ button to obtain the application and open it in the document editor.
2. Fill in the date and license number at the top of the form. Ensure accuracy, as this information is crucial for processing your request.
3. Enter your local ID number, VIN, and provider name. This identifies your ambulance service and must match your official records.
4. Provide the contact person's information, including their phone number, fax number, and email address.
5. List the EMS system hospital name to which your service is affiliated.
6. Indicate whether your personnel are volunteer/unpaid, volunteer/paid, or paid. This information provides context for your staffing situation.
7. Detail the exact nature of your staffing waiver request, including the reasons for the request and any specific circumstances.
8. Specify the length of the waiver requested, ensuring it does not exceed 12 months.
9. Select the vehicle level of care applicable to your waiver request: BLS, B/D, ILS, or ALS.
10. Indicate the hours during which the vehicle will be staffed and provide a description if the staffing pattern is complex.
11. Specify how the vehicle will be staffed at times other than those indicated above, following the same procedure as in the previous step.
12. State the date by which the vehicle will provide its licensed level of care 24 hours a day, 365 days a year.
13. Attach your detailed plan for providing 24-hour service throughout the year along with any relevant announcements about changes in service.
14. Include a list of all licensed ambulance vehicles, providing required details such as license number, VIN, local ID number, hours of operation, staff roster, and a sample staffing schedule for six weeks.
15. Obtain the necessary signatures and dates from the EMS Medical Director, EMS System Coordinator, and Regional EMS Coordinator as indicated on the form.
16. Once all sections are completed and signatures obtained, save your changes, and prepare to download, print, or share the form as required.

Take the next step in your application process. Complete and submit your (EMS) Systems Ambulance Staffing Waiver Request Application online today.