Application for EMS Operating Certificate
Forms Used in EMS Agency Application
- DOH-206 Application for EMS Operating Certificate Form (PDF, 1.92MB, 2pg.)
General Instructions for Initial Form Completion
The upper right hand corner of each section of the form has an item number that corresponds to the following. Please complete all the unshaded boxes as applicable to your service. The completed form and all required attachments must be submitted to your DOH Regional or Area Office in duplicate and your service should retain an additional full copy for your own records.
Incomplete, unsigned, undated or un-notarized submissions will be returned and considered as not having been submitted in compliance with Public Health Law.
Required information to complete
- This item should be blank. Renewal versions of this form received after your initial filing will indicate your certification expiration date.
- Check the box that indicates the type of service, Ambulance or Advanced Life Support First Response (non-transporting). You may not check both boxes.
- Legal Name of your service or corporation that holds your EMS Operating authority.. If your service has filed a DBA provide the DBA name in item #16.
- Your Federal Employer ID Number. NOTE: No service may voucher NYSDOH or seek reimbursements for any reason without a valid FEIN on file with the Department. If field is blank please fill it in.
- Do Not Change the number in this field. It is your DOH agency ID.
- The physical location (road, street and number) of your principal business location.
- The "business" mailing address for your service. Individual mailing address of a chief operating officer cannot be substituted without specific permission by DOH.
- Remainder of mailing address and county.
- The "business" telephone number of your service. If more than one then give number of principal location.
- Emergency Dispatch number called to activate your service. If your service is activated by local 911 then indicate 911 in this field.
- EMAIL address for your service (or for your chief operations officer if you do not have a service address).
- The "business" FAX number of your service.
- Check only ONE box to indicate the general organizational structure of your service.
- Check only ONE box to indicate the ownership of your service. Corporations circle For Profit or Not for Profit. Municipally owned services please circle specific identity of owner. State and Federal government services please indicate identity of owner.
- For all services EXCEPT corporations (for profit or not for profit) give the name or names of the Owner(s) of your service. Corporations leave this item BLANK. If insufficient room provide information on a separate sheet.
- All corporations must give full legal name of service as filed with appropriate state's division of corporations. Also identify any DBA filed. Provide separate list if needed. Names and personal information listed must be provided for all corporate officers. NOTE: Personal information provided in this field is confidential and not subject to FOIL or release by the Department unless otherwise provided by state law. Your corporation's officers information may be submitted on a separate sheet labeled "Confidential Information", but must be submitted for your application to be deemed complete.
- Name, title and contact phone numbers (day / night / 24 hrs) of your service's Chief Operating Officer.
- If your service is funded, even in part, by a Tax District of any kind please indicate and provide the name of the district.
- If your service is operated under contract or municipal authority by a separate entity, please complete the information in this item.
- If the level of care (LOC) your service currently provides is different from the level identified, cross out the incorrect level and check the box that correctly indicates your LOC. NOTE: You may not raise your LOC without written permission from your Regional Council's Medical Advisory Committee (REMAC) copied to NYS DOH.
- New services: Provide an estimate of your call volume. Do not indicate any estimate of non medical responses.
Also provide gross total budget in dollars for your service's last full fiscal year (non-commercial services only. "For Profit" services may leave this field item BLANK). For Not for Profit corporations, this will be the same value reported in compliance with US Tax Code to the US Dept of the Treasury (form 990, 990PF or 990EZ), or per NYS Executive Law 172(b) to the states' Attorney General as an Annual Financial Report, or to the Dept of State's Charities Bureau as a charitable institution. Combined services, such as Fire or Police Departments that also provide EMS, should report only the portion of your annual budget allocated to EMS. New services may estimate anticipated annual operating expense for coming year.
- Name, address, phone number and NYS Physician's license number of your service medical director. If more than one physician is serving as a medical director, please provide separate sheet with required information.
- Physical street address of each location at which any of your service's certified response vehicles are garaged. Provide a separate sheet if more than 3 locations.
- Number of certified response vehicles. NOTE: Only an Advanced Life Support First Response Service may operate "First Response" class certified vehicles. Non-transport emergency vehicles operated by an ambulance service are legally designated as EASVs in compliance with NYS motor vehicle law.
- This is your service's authorized operating territory. You may not add territory to the description printed in this field. If it does not correctly indicate the area served by your service please contact NYS DOH Bureau of EMS to report the discrepancy. New Services: check with DOH to verify this information
- Give 3 values in this item. The total number of employees / members in your service, the number that are volunteer and the number that are paid, either full or part time.
- Fill in the number of members / employees that are certified at each level; CFR, EMT, AEMT-Intermediate, AEMT- Critical Care and AEMT- Paramedic. Do not count individuals that are not documented on your agency personnel roster as currently certified.
- Fill in dispatch methods, frequencies and communications resources used by your service. If your service has its own FCC issued license, please give the callsign.
- This is a list of the required supporting documents and attachments. Not listed here but also required is your Medical Director Verification form with the signature of the physician that provides oversight to your service. The level of patient care you indicated in item 20 must match the level of care identified by your medical director.
- Do not write in the shaded box. Print the name and title of the person signing your application. Be sure to read the agency statement of certification and have the form notarized and dated. Signature must be by service Owner, Chief Executive Officer or Chief Operating Officer.