Form Doh-5136 - Application And Approval For Ems Agency To Submit E-Pcrs

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NEW YORK STATE DEPARTMENT OF HEALTH
Application and Approval for EMS Agency to Submit e-PCRs
Bureau of Emergency Medical Services and Trauma Systems
BEFORE PURSUING ANY e-PCR SYSTEM, CONTACT YOUR REGIONAL EMS PROGRAM AGENCY TO NOTIFY THEM OF YOUR INTENT.
The Program Agency will assist you with best practices on evaluating and choosing an e-PCR software product. Then, once you’ve
chosen a product, the Program Agency will guide you in completing this and other required documents to apply for Regional
Endorsement and NYSDOH approval to submit e-PCRs.
YOU MUST HAVE NYSDOH APPROVAL BEFORE IMPLEMENTING OR CHANGING YOUR e-PCR SYSTEM.
This Form Is: (Check One)
An original application for the EMS Agency to convert from paper PCRs to an e-PCR system.
Updating information about the EMS Agency and its e-PCR system already approved by NYSDOH.
EMS Agency
NYS Agency Code ________________ Agency Name__________________________________________________________
Primary e-PCR Coordinator Name __________________________________________________________________________
Day Phone ( _____ ) ______________ Cell Phone ( _____ ) _____________ E-mail _________________________________
Secondary e-PCR Coordinator Name ________________________________________________________________________
Day Phone ( _____ ) ______________ Cell Phone ( _____ ) _____________ E-mail _________________________________
e-PCR Software Product
Vendor Name_________________________________________________________________________________________
Home Office Address ___________________________________________________________________________________
City__________________________________________________________________ State _________ ZIP ____________
Software Name _______________________________________________________________________________________
Is this software: NEMSIS Version 2 Gold Compliant?
Yes
No NEMSIS Version 3 Collect Data [Agency] Compliant?
Yes
No
Primary Vendor Contact Name ____________________________________________ Title _______________________
Day Phone ( _____ ) ______________ Cell Phone ( _____ ) _____________ E-mail _______________________________
Vendor Technical Support Person Name_______________________________________ Title ________________________
Day Phone ( _____ ) ______________ Cell Phone ( _____ ) _____________ E-mail ________________________________
Third Party Involvement (Complete only if a third party will manage the e-PCR system for the EMS Agency.)
Relationship to EMS Agency:
Billing Company
EMS Region
County
Other EMS Agency
Other (Specify)________________________________
Business Name _______________________________________________________________________________________
Office Address ________________________________________________________________________________________
City__________________________________________________________________ State _________ ZIP _________
Third Party Contact Name ________________________________________________ Title ________________________
Day Phone ( _____ ) ______________ Cell Phone ( _____ ) _____________ E-mail ________________________________
DOH-5136 (4/15) Page 1 of 3

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