Get Bhs/ems-352 - State Of Michigan - Mich

This guide provides step-by-step instructions for completing the BHS/EMS-352 application form required for operating a life support agency in Michigan. By following these guidelines, users can navigate the form easily and ensure compliance with state regulations.

Follow the steps to successfully complete the BHS/EMS-352 form.

1. Click the ‘Get Form’ button to access the BHS/EMS-352 application form and open it in your preferred editing tool.
2. Begin by selecting the level of service being requested in section 1: Basic, Limited Advanced, or Advanced. Check the appropriate box to indicate your choice.
3. In section 2, enter the name of your Life Support Agency as required.
4. Fill out the mailing address in section 3, including federal I.D. number, city, state, and zip code.
5. Provide details for the contact person in section 4, including their name, business phone number in section 5, and optional email address in section 6.
6. List vehicles for which authorization is being requested in section 7. A completed Part 2 application must accompany this information.
7. For section 8, indicate if your agency operates under any other names. If yes, specify those names.
8. Document mutual aid agreements with other agencies in section 9 and be prepared to present copies at inspection.
9. In section 10, list the geographic service areas where pre-hospital care will be provided.
10. Confirm acknowledgment of required criteria in section 11 and the MEDCOM requirements in section 12.
11. Name each medical control authority your service area falls under in section 13.
12. Obtain and provide signatures from the Medical Control Authority and the legally responsible person in sections 14 and 15, respectively.
13. Once all sections are filled out accurately, review your application for completeness, then save your changes, download, print, or share the form as needed.

Complete your BHS/EMS-352 application online today to ensure your life support agency can operate legally.