Form Ioci 12-235 - Request To Modify, Amend Approved System Plan - Illinois Department Of Public Health
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1State of Illinois
Illinois Department of Public Health
Emergency Medical Services (EMS) Systems
Request to Modify / Amend Approved System Plan
This form is to be completed to request an amendment to a currently approved EMS system plan and a currently approved provider.
Incomplete applications will be returned to the resource hospital for completion.
EMS Medical Director Name (print) ___________________________________________________________________________________
Resource Hospital Name_____________________________________________________ EMS System Number __________________
Address _______________________________________________________________________________________________________
City/State ____________________________________________________________________ ZIP Code ________________________
Provider Name (print) _________________________________________________ Provider Number _____________________________
Provider City/State ________________________________________________________________________________________________
License Number
VIN
Current Level
Requested Level
Check the appropriate items:
Request to:
Upgrade
Downgrade
Request for:
Provider
Vehicle(s)
Level of Care
From:
First Responder
BLS
ILS
ALS
B/D
To:
First Responder
BLS
B/D
ILS
ALS
CCT
Modify Response Area of Above Provider. List changes on separate sheet and attach. Include description of response area, map
indicating each vehicle response area, square miles, population, location of resource/associate hospital, and vehicle location.
Modify Access and Dispatch Procedures and Mechanisms (Describe and attach)
Additional or Replacement Vehicles (Illinois Department of Public Health inspection required)
Other (Describe and attach)
______________________________________________________________________________
_____________________________
Signature of Applicant
Date
EMS System Approval
I have reviewed the above request and verify that this licensee meets the vehicle, equipment and staffing requirements of the regulations
and our EMS system plan for the requested level of care, and recommend approval of this application.
______________________________________________________________________________
_____________________________
EMS Medical Director / EMS System Coordinator Signature
Date
REMSC Review
Recommended
Not Recommended
Discuss
______________________________________________________________________________
_____________________________
Regional EMS Coordinator Signature
Date
Central Office
Processed on ______/______/______
IOCI 12-235
12/11
Printed by Authority of the State of Illinois
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