Form Doh-5136 - Application And Approval For Ems Agency To Submit E-Pcrs (Page 2 of 3) in pdf

EMS Region(s)

Starting with the EMS Region in which the EMS Agency is home based, list all NYS EMS Regions in which the EMS Agency operates.

__________________________________________________________________________________________________

Attach to this form the following items, as required by the Region/NYSDOH. (If nothing indicated, no attachments are required.)

__________________________________________________________________________________________________

Data Submission and Use Agreement

Who will be responsible for submitting the EMS Agency’s e-PCR data to the EMS Region and NYSDOH?

EMS Agency Personnel

e-PCR Software Vendor

Billing Company

EMS Region

County

Other EMS Agency

Other (Specify)______________________________________________________________________________________

• Under Article 30 of NYS Public Health Law (§3004-A Regional Emergency Medical Advisory Committees, §3006 Quality Improvement

Program, §3011 Powers and Duties of the Department and The Commissioner, and §3053 Reporting), EMS Agencies are required to com-

plete detailed individual call reports and submit the data from such reports to the EMS Region and NYSDOH for use in quality improve-

ment programs. Article 30 further holds that any “information . . . collected . . . shall be kept confidential and shall not be released except

to the department or pursuant to [a quality improvement program]” (§3006). Other Federal and State regulations apply.

• Although the EMS Agency may delegate management of its e-PCR system to a third-party, the EMS Agency remains responsible for

the timely submission of PCR data to the EMS Region and the NYSDOH; as well as legal responsible for assuring the proper collection,

submission, use, protection, and confidentiality of any data entered into or contained within the EMS Agency’s e-PCR system.

• All signatories on this form attest that their respective entities abide by all applicable Federal and State rules governing the collection,

submission, use, protection, and confidentiality of electronic patient healthcare information, and agree to assist each other in assuring

the protection and confidentiality of any data exchanged between them.

“Go-Live” Agreement

By what date is the EMS Agency planning to “go live” with this e-PCR system? ________________________________________

CONSULT WITH YOUR REGIONAL EMS PROGRAM AGENCY BEFORE CHOOSING THIS DATE.

THE EMS AGENCY MUST HAVE STATE APPROVAL BEFORE GOING LIVE.

• This date cannot be less than 30 or more than 120 days after the date of the EMS Agency Official signature on this form.

• If the EMS Agency encounters difficulties that will impact this date, the EMS Agency must contact the Program Agency immediately

to amend this application.

IF THE EMS AGENCY IS CONVERTING FROM PAPER TO ELECTRONIC PCRs: By this date, the EMS Agency must “go live” with this e-PCR

system; at which time the Program Agency will no longer provide new paper PCRs to, or accept completed paper PCRs from, the EMS

Agency; but until that time, the EMS Agency must continue to submit paper-PCRs as per usual.

IF THE EMS AGENCY IS CHANGING e-PCR SYSTEMS: By this date, the EMS Agency must “go live” with its new system, and discontinue use

of its previous system; but until that time, the EMS Agency must continue to use its previous system.

DOH-5136 (4/15) Page 2 of 3

Form Doh-5136 - Application And Approval For Ems Agency To Submit E-Pcrs Page 2