Original Application for Ambulance and ALSFR Agency Operational Authority
Important New Information
Enclosed is an application for your EMS operating certificate. Please note that this form may be partially "populated" with the information that the Department has currently on file for your EMS service. If so, then review the sections pre-filled carefully and correct or update it as necessary. Please insure that you complete the following:
- All applicable areas of the form that are not filled in.
- Make sure that the corporate officers and their addresses are indicated if your entity is a corporation. Municipalities and Districts may leave section 16 blank.
- Complete the Affirmation of Compliance.
- Make sure that the application and affirmation are signed and notarized.
- Provide the Department with the original and one copy.
- Keep a copy for your records
As a reminder, review Article 30/30A of the Public Health Law and Part 800 of the Codes, Rules and Regulations to insure compliance with all requirements. Make sure that the completed application is submitted to the Department prior to your service expiration date if the application is a renewal.
The completed renewal application packet must include the original and one copy of the following:
Forms Used in Completing the EMS Agency Application
- Department of Health Forms Commonly Used by EMS Providers
- DOH-206 Application for EMS Operating Certificate (PDF, 17KB, 2pg.)
- DOH-1881 Affirmation of Compliance (PDF, 124KB)
- DOH-2828 EMS Agency Personnel Roster (PDF, 12KB, 1pg.)
- DOH-3777 Application for New EMS Service, Expansion of Territory or Transfer of Ownership (PDF, 795KB, 2pg.)
- DOH-3778 Affirmation of Fitness and Competency (PDF, 28KB, 2pg.)
- DOH-4362 Medical Director Affirmation Form (PDF, 18KB, 1pg.)
Directions for Completing Specific Forms
Completed Application Packet
The packet must be mailed to your Regional Department of Health EMS Representative.