Get Doh-5208 Notice Of Intent To Provide Ambulance Transfusion Services - Health Ny

The DOH-5208 Notice Of Intent To Provide Ambulance Transfusion Services is a crucial document for ambulance services intending to offer transfusion services. This guide provides clear, step-by-step instructions for filling out the form online to ensure a seamless submission process.

Follow the steps to complete your form effectively.

1. Press the ‘Get Form’ button to access the DOH-5208 Notice Of Intent To Provide Ambulance Transfusion Services document. This will enable you to view the form in an editable format.
2. Begin by filling out the ambulance service information section. Include the date of the notification, the name of your organization, and the contact details of the primary contact person, including their email address and telephone number.
3. Provide the address of the organization, including city, state, and ZIP code. Ensure all information is accurate to avoid any delays in processing.
4. Select the type of ownership by checking the appropriate box, choosing from options such as Fire Department, Commercial, Municipal/Government, Independent, Hospital Owned, Industrial, or College/University.
5. Indicate the level of care as approved by the local Regional Emergency Medical Advisory Committee (REMAC) and recognized by the Department of Health Emergency Medical Services (DOH EMS). Options include EMT – Critical Care or EMT – Paramedic.
6. Specify the type of ambulance service you will provide by selecting 'Air,' 'Ground,' or 'Both.' This distinction is vital for service categorization.
7. In the Education Program Information section, enter the name of the course sponsor and the number of trained EMS providers. Ensure to include details about EMT-Paramedics and EMT-Critical Care Technicians, if applicable.
8. Complete the section regarding the service medical director. Include the name, NYS license number, address, and telephone number of the ambulance service physician medical director.
9. In the Authorization Names and Signatures section, print and sign the required names: CEO or designee, medical director, Bureau of EMS representative, and Blood and Tissue Resource Program representative. Date each signature.
10. Review all entries for accuracy and completeness. Once confirmed, you can choose to save changes, download, print, or share the completed form for submission.

Complete your DOH-5208 form online today for efficient processing!