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.
EMS Agency Operations
- DOH-206 Application for EMS Operating Certificate (PDF, 17KB, 2pg.)
- DOH-1881 Affirmation of Compliance (PDF, 372KB, 2pg.)
- DOH-2936 Certified EMS Agency Information Update Form (PDF, 89KB, 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-3848 Controlled Substances Semi-Annual Report For EMS Agencies (PDF, 61KB, 1pg.)
- DOH-4352 Fentanyl Quarterly Report Form for EMS Agencies (PDF, 21KB, 1pg.)
- DOH-4362 Medical Director Affirmation Form (PDF, 18KB, 1pg.)
- Clinical Laboratory Evaluation Program - Permit Application Materials
EMS Education and Certification
- DOH-65 Application for Emergency Medical Services Certification (PDF, 33KB, 2pg.)
- DOH-80 Notice of Course Cancellation (PDF, 16KB, 1pg.)
- DOH-263 Course Memorandum (PDF, 45KB, 2pg.)
- DOH-3312 Verification of Membership in A NYS EMS Agency (PDF, 18KB, 1pg.)
- DOH-4010 Application for AEMT Rapid Recertification (PDF, 53KB, 2pg.)
- DOH-4245 Registration For Emergency Medical Technicians' Exam, Test Scheduling Request (PDF, 25KB, 1pg.)
- DOH-4260 Registration For On-Site Scored NYS Written Certification Exams (PDF, 102KB, 2pg.)
- DOH-4281 Certification Extension for Military Personnel (PDF, 18KB, 1pg.)
- DOH-4451 CLI Internship Tracking Form (PDF, 121KB, 1pg.)
- DOH-4452 CIC Internship Tracking Form (PDF, 121KB, 1pg.)
- DOH-4453 Duplicate Card Request (PDF, 136KB, 1pg.)
CME Pilot Recertification Program
Beginning January 1, 2005, these are the only forms that will be accepted.
All recertification forms must be postmarked no later than 45 days prior to your expiration date.
- DOH-4226 Participant Registration Form (PDF, 17KB, 2pg.)
- DOH-4227 Agency Registration Form (PDF, 115KB, 2pg.)
- DOH-4228 EMT-Basic Recertification Form (PDF, 81KB, 3pg.)
- DOH-4229 AEMT-Intermediate Recertification Form (PDF, 23KB, 2pg.)
- DOH-4230 AEMT-Critical Care Recertification Form (PDF, 76KB, 2pg.)
- DOH-4231 AEMT-Paramedic Recertification Form (PDF, 65KB, 2pg.)
Reciprocity
- DOH-2177 EMT Sheet for Reciprocity (PDF, 77KB, 1pg.)
- DOH-2178 Verification of EMT Certification (PDF, 85KB, 1pg.)
- DOH-2183 Application Form for New York State EMT Reciprocity (PDF, 43KB, 1pg.)
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, 4pg.)
- DOH-2225K Mass Gathering and Public Function Fee Determination Schedule (PDF, 361KB, 1pg.)
- DOH-2332 Part 18 Public Function Event Report (PDF, 46KB, 1pg.)
- DOH-2342 Part 18 Public Function Medical Incident Log (PDF, 454KB, 1pg.)
Do Not Resuscitate (DNR) Order
- DOH-3474 Nonhospital Order Not To Resuscitate (DNR Order) (PDF, 24KB, 1pg.)
- Nonhospital Order Not To Resuscitate (DNR Order) Information Brochure (PDF, 46KB, 2pg.)
Notices of Intent
- DOH-4135 Notice of Intent to Provide Public Access Defibrillation (PAD) (PDF, 147KB, 1pg.)
- DOH-4188 Notice of Intent to Possess and Use Epinephrine Auto Injector (PDF, 8KB, 1pg.)