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

Affirmations

We, the undersigned, make application for this EMS Agency to implement and use the e-PCR system described here to document and submit

to the NYS Department of Health and its Regional EMS System partners, as required under Public Health Law, pre-hospital care data.

We affirm:

1. We have read, understand, and agree to all information contained in this application, including the "Data Submission and Use

Agreement" and "Go-Live Agreement";

2. We have authorization from the Governing Body of this EMS Agency to make such application;

3. We, the Governing Body, and this EMS Agency as a whole, understand and agree to abide by the stipulations outlined in this

application, as well as all statutes, regulations, and policies pertaining to e-PCRs; and

4. That once this EMS Agency has converted to electronic PCRs, it will no longer submit paper PCRs and will not return to paper PCRs.

EMS Agency Official (Authorized by the Governing Body to Commit the EMS Agency to this Agreement)

Name________________________________________________________ Title _________________________________

Signature _____________________________________________________ Date _________________________________

EMS Agency Primary e-PCR Coordinator

Name________________________________________________________ Title _________________________________

Signature _____________________________________________________ Date _________________________________

Third Party Representative (If Applicable)

Name________________________________________________________ Title _________________________________

Signature _____________________________________________________ Date _________________________________

Regional Endorsement and NYSDOH Approval

If appropriately signed below, this EMS Agency has been endorsed by its EMS Region and approved by the Department of Health

to implement and use the e-PCR system described here to document and submit to the NYS Department of Health and its Regional

EMS System partners as required under Public Health Law, pre-hospital care data. The Department reserves the right to amend

or revoke this approval at any time, given due process to the EMS Agency.

Regional Endorsement

Region N ame _______________________________________________________________________________________

Name Program Agency Official _____________________________________________ Title ______________________

Signature _____________________________________________________ Date _________________________________

NYSDOH – Bureau of EMS and Trauma Systems Approval

Name___________________________________________________________________ Title ______________________

Signature _____________________________________________________ Date _________________________________

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

Form Doh-5136 - Application And Approval For Ems Agency To Submit E-Pcrs Page 3