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S-SV EMS Agency
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Policy Manual
Table of Contents
100 – State Law & Regulation
200 – Local EMS Agency (LEMSA)
300 – Hospitals
400 – Provider Agencies
500 – Patient Destination
600 – Documentation & QI
700 – Equipment & Supplies
800 – Field Policies & Treatment Protocols
900 – EMS Personnel
1000 – Training Programs
1100 – Procedure Policies
Protocols (ALS/BLS)
Cardiovascular (ALS/BLS)
Respiratory (ALS/BLS)
Medical (ALS/BLS)
Neurological (ALS/BLS)
OB/GYN (ALS/BLS)
Environmental (ALS/BLS)
Trauma (ALS/BLS)
Pediatric (ALS/BLS) Protocols
Protocols (LALS)
Cardiovascular (LALS)
Respiratory (LALS)
Medical (LALS)
Neurological (LALS)
OB/GYN (LALS)
Environmental (LALS)
Trauma (LALS)
Pediatric (LALS – AEMT) Protocols
HPP
EMR Recertification Application
Please enable JavaScript in your browser to complete this form.
Name
*
First
Middle
Last
Birthdate
*
Address
*
Address Line 1
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Email Address
*
Telephone Number
*
Certification Expiration Date
*
Current EMR Certification Number
EMS Employer (if applicable)
*
How Many Application File Attachments Do You Have To Upload? (3 MB Max File Size Per Attachment)
1
2
3
4
Please see "Recertification Instructions" on the previous page for a list of required documents. Any documents that are unable to be uploaded can be e-mailed to our mailbox: INFO @ ssvems.com
File Upload
Click or drag a file to this area to upload.
File Upload
Click or drag a file to this area to upload.
File Upload
Click or drag a file to this area to upload.
File Upload
Click or drag a file to this area to upload.
Background Information
ATTENTION: If you answer yes to any of the following background questions, you must attach or submit a letter of explanation.
Have you ever been convicted of a felony or misdemeanor offense in California or any other state/place, including a plea of nolo contendere/no contest and, including any conviction which has been expunged under Penal Code Section 1203.4?
*
Yes
No
Are you currently under criminal investigation or are there any criminal charges currently pending against you?
*
Yes
No
Have you ever had a certification, accreditation, or professional healing arts license denied, suspended, revoked, or placed on probation, or are you under investigation at this time?
*
Yes
No
Attestation and Electronic Signature
By typing my name in the signature box and entering today's date, I hereby certify under penalty of perjury that all information is true and correct to the best of my knowledge and belief. I understand that any falsification or omission of material facts may cause forfeiture on my part of all right to EMR certification in the state of California. I understand all information on this application is subject to verification, and I hereby give my express permission for the S-SV EMS Agency to contact any person or agency for information related to my role and function as an EMR. I understand that I may be required to provide copies of legal records related to my past criminal activity (if applicable), and the processing of my application may be delayed until these documents are provided to the satisfaction of the S-SV EMS Agency, I understand that I am solely responsible for notifying the S-SV EMS Agency in writing, within (30) calendar days, of any and all changes of my mailing address.
SIGNATURE
*
Date
*
Phone
Submit