Department of Health Forms Commonly Used by EMS Providers
The forms listed below are the ones most commonly used by EMS providers and agencies. We have placed these files here to assist you.
For additional assistance contact the Bureau of EMS or your Regional EMS Representative.
Vouchers
- Agency Claim for Payment Voucher - AC3253-S (PDF, 67KB)
- Course Sponsor Claim for Payment Voucher - AC3253-S (PDF, 69KB)
- Proctor Claim for Payment for Non-State Employees - AC3253-S (PDF, 68KB)
EMS Operations
Agency
- DOH-206 Application for EMS Operating Certificate (PDF, 17KB)
- DOH-1881 Affirmation of Compliance (PDF, 372KB)
- DOH-2936 Certified EMS Agency Information Update Form (PDF, 25KB)
- DOH-3777 Application for New EMS Service, Expansion of Territory or Transfer of Ownership (PDF, 795KB)
- DOH-3778 Affirmation of Fitness and Competency (PDF, 28KB)
- DOH-4362 Medical Director Affirmation Form (PDF, 18KB)
- DOH-4461 Reportable Incident Form (PDF, 562KB)
- Rotary Wing AMS Equipment Waiver Approval (PDF, 53KB)
- Clinical Laboratory Evaluation Program - Permit Application Materials
Controlled Substances
- DOH-2094 Loss of Controlled Substances Report (PDF, 54KB)
- DOH-3826 Application for ALS Agency to Engage in Controlled Substances Activity for Pre-Hospital Care (PDF, 1.5MB)
- DOH-3827 Application to be a Controlled Substance Agent for an ALS Agency (PDF, 643KB)
- DOH-3848 Controlled Substances Semi-Annual Report For EMS Agencies (PDF, 61KB)
- DOH-4352 Fentanyl Quarterly Report Form for EMS Agencies (PDF, 21KB)
- DOH-5012 Ketamine Quarterly Report Form for EMS Agencies (PDF, 94KB)
EMS Education and Certification
Education
- AEMT Rapid Recertification Administrative Manual (PDF, 25KB, 4pg.)
- DOH-89 Certified Class List for Ancillary EMS Training Courses (PDF, 54KB)
- DOH-80 Notice of Course Cancellation (PDF, 11KB)
- DOH-263 Course Memorandum (PDF, 50KB)
- DOH-743 Instructor Information Sheet (PDF, 14KB)
- DOH-2423 Lab Instructor Audit Report (PDF, 620KB)
- DOH-2424 Didactic Presentation Audit Report (PDF, 44KB)
- DOH-2733 Final Practical Skills Examination Summary Sheet (PDF, 367KB)
- DOH-3377 CIC Internship Completion Report (PDF, 36KB)
- DOH-3378 CLI Internship Completion Report (PDF, 38KB)
- DOH-4451 CLI Internship Tracking Form (PDF, 121KB)
- DOH-4452 CIC Internship Tracking Form (PDF, 121KB)
Certification
- DOH-65 Application for Emergency Medical Services Certification (PDF, 60KB)
- DOH-79 Students Ineligible To Take The State Certifying Examination (PDF, 65KB)
- DOH-2260 Application for Instructor Certification (PDF, 79KB)
- DOH-3312 Verification of Membership in A NYS EMS Agency (PDF, 18KB)
- DOH-3379 Medical Director's Certification of AEMT Course Completion (PDF, 30KB)
- DOH-3508 Application for Instructor Recertification (PDF, 116KB)
- DOH-4010 Application for AEMT Rapid Recertification (PDF, 53KB)
- DOH-4245 Registration For Emergency Medical Technicians' Exam, Test Scheduling Request (PDF, 33KB)
- DOH-4260 Registration For On-Site Scored NYS Written Certification Exams (PDF, 167KB)
- DOH-4281 Certification Extension for Military Personnel (PDF, 18KB)
- DOH-4453 Duplicate Card Request (PDF, 136KB)
CME Pilot Recertification Program
All recertification forms must be postmarked no later than 45 days prior to your expiration date.
- DOH-4226 Participant Registration Form (PDF, 237KB)
- DOH-4227 Agency Registration Form (PDF, 115KB)
- DOH-4228 EMT-Basic Recertification Form (PDF, 37KB)
- DOH-5064 Supplement Form
- DOH-5065 EMT Recertification Form 2012
- DOH-5066 AEMT Critical Care Recertification Form 2013
- DOH-5067 AEMT Recertification Form 2013
- DOH-4231 Paramedic Recertification Form 2013
Reciprocity
- Information Packet for New York State EMT Reciprocity (Ver 04/2013) (PDF, 60KB)
- DOH-2177 EMT Sheet for Reciprocity (PDF, 77KB)
- DOH-2178 Verification of EMT Certification (PDF, 85KB)
- DOH-2183 Application Form for New York State EMT Reciprocity (Ver 04/2013) (PDF, 353KB)
Miscellaneous Forms
Part 18 - Public Gathering and Public Function
- DOH-44 Application for a Permit for a Public Gathering (Part 18 of 10 NYCRR) (PDF, 1,658KB)
- DOH-2225K Mass Gathering and Public Function Fee Determination Schedule (PDF, 361KB)
- DOH-2332 Part 18 Public Function Event Report (PDF, 46KB)
- DOH-2342 Part 18 Public Function Medical Incident Log (PDF, 454KB)
Do Not Resuscitate (DNR) Order/MOLST
- DOH-3474 Nonhospital Order Not To Resuscitate (DNR Order) (PDF, 9KB)
- DOH-3474es Nonhospital Order Not To Resuscitate, Spanish Version (DNR Order) (PDF, 10KB)
- DOH-5003 Medical Orders for Life-Sustaining Treatment (MOLST) (PDF, 115KB)
