Get Request To Modify/amend Approved System Plan - Illinois ... - Idph State Il

Filling out the Request To Modify/Amend Approved System Plan form is an essential step for any emergency medical services provider looking to update their approved plan. This guide provides clear, step-by-step instructions to ensure that you complete the form accurately and efficiently, enhancing your experience in the online submission process.

Follow the steps to fill out the online form accurately.

1. Click the ‘Get Form’ button to access the Request To Modify/Amend Approved System Plan form and open it in your designated editor.
2. Start by filling in the EMS Medical Director Name in the designated field on the form. This should be the name of the individual responsible for overseeing the EMS operations.
3. Input the Resource Hospital Name in the specified section. This is the hospital associated with your EMS system.
4. Enter the EMS System Number accurately to ensure your submission is linked to the correct system.
5. Provide the address for the Resource Hospital, including the city and state.
6. Fill in the Provider Name and their ZIP Code. Ensure this information is clearly printed.
7. Complete the Provider Number and Provider City/State fields accurately.
8. Indicate the License Number and Vehicle Identification Number (VIN) as applicable.
9. Specify the Current Level and Requested Level by selecting the appropriate options from the provided checkboxes.
10. Check the box that represents your request type, whether it’s an upgrade or downgrade. Also, select the relevant requests regarding First Responder, BLS, ILS, ALS, or B/D.
11. If applicable, provide detailed descriptions of any modifications to the response area, dispatch procedures, access mechanisms, or additional vehicles. Attach separate sheets if necessary.
12. Sign and date the application in the designated sections to verify your request.
13. After completing the form, review all entries for accuracy. Save changes, and download or print the document if required for your records.
14. Submit your completed form online according to the submission guidelines provided by the Illinois Department of Public Health.

Take action now and complete your Request To Modify/Amend Approved System Plan online for a smoother EMS operation.