Get Ma Oems Form 500-1 2011

Filling out the MA OEMS Form 500-1 is a vital process for ambulance service license applications in Massachusetts. This guide provides a clear, step-by-step approach to assist you in accurately completing the form online.

Follow the steps to properly complete the MA OEMS Form 500-1.

1. Click ‘Get Form’ button to access the MA OEMS Form 500-1. This will open the form in your preferred online editor.
2. Fill in the service number and service expiration date accurately. Ensure that the dates are current and correspond to your service records.
3. Indicate whether this application is for an initial or renewal request by selecting the appropriate option.
4. In the service information section, provide the name, address, city, state, business phone number, and contact person details, including email.
5. Complete the licensee information by entering the name, address, and contact details of the business owner or organization.
6. List any parent or associated companies of the owner with their respective contact information.
7. Specify the type of service ownership, selecting from sole proprietor, government, partnership, corporation, limited partnership, or other.
8. Answer whether the service is operated by a state agency and specify the level of license applying (BLS, Intermediate, or Paramedic).
9. Provide details on your hospital affiliations, listing the names of hospitals with which you have agreements.
10. Enter the total number of vehicles and EMS personnel, differentiated by class and level (Basic, Intermediate, Paramedic).
11. Indicate if your service responds only to calls from a unique population and, if applicable, identify that population.
12. Record the total number of runs resulting in patient transport for the last calendar or fiscal year, including emergency runs.
13. If applicable, check any existing waivers and enter the waiver type while providing totals as required.
14. Confirm whether there are any outstanding assessments, ensuring you address any compliance issues as necessary.
15. Complete the certification statement related to tax compliance, signing and dating as required.
16. Once all information has been provided, review for accuracy, save changes, and choose to download, print, or share the completed form.

Complete your MA OEMS Form 500-1 online today to ensure a smooth application process for your ambulance service license.