Hospital Emergency Medical Services Classification Report Form
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1Oklahoma State Department of Health
P
ROTECTIVE
Protective Health Services
Medical Facilities
H
th
EALTH
1000 NE 10
Street
Oklahoma City, OK 73117-1299
S
Telephone: (405) 271-6576
ERVICES
FAX: (405) 271-1141
Hospital Emergency Medical Services Classification Report
License Number: ____________
(Please print)
Name of Hospital _____________________________________________________________________________
Address: ____________________________________________________________________________________
____________________________________________________________________________________________
City
State
Zip Code
Mark the appropriate box for the level of service provided for each of the emergency services listed below according
to the requirements of OAC 310:667-59-1 through 310:667-59-25.
Level of Service Provided
Emergency Service
IV
III
II
I
1
Trauma and emergency operative services
Emergency cardiology services
Emergency pediatric medicine and trauma services
Emergency dental services
Emergency obstetrics and gynecologic services
Emergency ophthalmology services
Emergency neurology services
Emergency psychiatric services
Emergency general medicine services
Level of Service Provided
Emergency Stroke Services
Primary
Secondary
Stroke Center
Stroke Facility
Classification
1
Hospitals holding a current verification certificate as a Level I or Level II trauma center from the American College of Surgeons
Committee on Trauma (ACS COT) may be classified at Level I or Level II for Trauma and emergency operative services. Hospitals
holding ACS COT verified status must include a copy of their current ACS COT verification certificate.
The undersigned attests that to the best of his or her knowledge and belief, the above named institution
provides emergency medical services at the Levels reported here according to the provisions of the Oklahoma
Statutes and to the regulations adopted thereunder by the State Board of Health.
Signature: _______________________________________________________
Date: ______/_____/_____
Title or Position: ______________________________________________________________________________
Oklahoma State Department of Health – Protective Health Services
ODH Form 911(Rev. 11/09)
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