Advanced Life Support Affiliation Agreement Template printable pdf download

This template includes the current regulatory minimum elements the Massachusetts Department of Public Health

requires for affiliation agreements between hospitals and ambulance services for medical control pursuant to

105 CMR 130.1501-1504 (Hospital Licensure regulations regarding medical control) and 105 CMR 170.300 (EMS

System regulations). As with any contract, all parties should seek the advice of their legal counsel prior to

signing.

Advanced Life Support Affiliation Agreement

This Agreement made and entered into on the ___#___day of ___month_____, 20____, between

Name of Hospital (hereinafter called “the Hospital”)

and

__Name of Ambulance Service

(hereinafter called “the

Service”).

Preamble:

• The Hospital is licensed by the Massachusetts Department of Public Health (MDPH) to

provide medical control services to ambulance services, pursuant to 105 CMR 130.1501-

1504; and

• The Service is licensed by MDPH to provide Advanced Life Support (ALS) Emergency

Medical Services (EMS), in accordance with 105 CMR 170.000 and its Emergency

Medical Technicians (EMTs) are certified at the appropriate ALS level of care to allow

the Service to deliver ALS at its particular level of licensure; and

• The MDPH regulations cited above require hospitals licensed to provide medical control

services and ambulance services licensed at the ALS level to enter into affiliation

agreements, which are current written contracts containing a reasonable and effective

plan for medical control.

THE PARTIES AGREE AS FOLLOWS:

The Hospital Agrees:

1. To provide medical oversight to the Service as it operates in

define the service area

covered by the Agreement.

2. To designate the physician named below, who meets the requirements set forth in 105

CMR 130.1504, as the Affiliate Hospital Medical Director (AHMD) to perform the

duties specified in 105 CMR 130.1503, including but not limited to, the authority over

the ALS clinical and patient care aspects of the affiliated service, including but not

limited to the authorization to practice of its EMS personnel.

3. To provide on-line medical direction by hospital-based physician(s) appropriately

credentialed and trained in accordance with the requirements of 105 CMR 130.1504, 24

hours a day, seven days a week and to ensure that all field communication of emergency

on-line medical direction is recorded by Coordinated Medical Emergency Direction

(CMED), at the hospital, or by other means.

Advanced Life Support Affiliation Agreement Template