Get Medical Command Authorization Application - Upmc.com

Filling out the Medical Command Authorization Application is essential for advanced practitioners who wish to establish their credentials with an EMS agency. This guide offers clear and comprehensive steps to help you navigate the form with ease and assure that all necessary information is accurately submitted.

Follow the steps to complete the application form successfully.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill out the credential date period, indicating the start and end dates for your medical command authorization.
3. Provide your personal details in the designated fields: Last Name, First Name, Middle Initial, Mailing Address, City, State, Zip Code, and Phone Number.
4. Select the appropriate check box for your certification level: AEMT, Paramedic, PHRN, PHPE, or PHP.
5. Enter your certification number and its expiration date in the provided fields.
6. Indicate your EMS agency name and any affiliate number, if applicable.
7. List any EMS agencies where you previously had medical command authorization, including the corresponding dates.
8. Respond to questions regarding past restrictions on your medical command authorization and any disciplinary sanctions, providing explanations if necessary.
9. Complete the section on other certifications, providing expiration dates for BCLS, ACLS, ITLS/PHTLS, and PALS.
10. Document the date of your last annual skill assessment.
11. Review the certification statement and sign to affirm the accuracy of the information provided; include the date of your signature.
12. Ensure that all required documentation is prepared for submission, including the EMS Provider Credential Form and additional certifications.
13. After verifying all information, save changes, and then download, print, or share the form as needed.

Get started now and complete your application online for a seamless experience.