CALIFORNIA WILDFIRE MEDICAL ASSOCIATION

PROVIDER APPLICATION
Provider Business Name*
Business Address*

Street Address

Mailing Address

CityState / Province

Postal / Zip Code
Business Phone Number*
Please enter a valid phone number.
Primary Owner Name*

First NameLast Name
Owner Phone Number*
Please enter a valid phone number.
Number of Years in Business
Primary Manager Name*

First NameLast Name
Primary Manager Phone Number*
Please enter a valid phone number.
Medical Director Name*

First NameLast Name and Title
Medical Director Phone Number*
Please enter a valid phone number.
List States Medical Director License Held In*
Check all that apply

Pay meets or exceeds all California Healthcare Provider Minimum Wage Requirements.If requested by incident, Can provide proof of Business Liability InsuranceCan provide DOT Inspection Documentation on all transport vehicles.Meets formulary requirements of FIRESCOPE and NWCGMedical Director License is current in state where business is licensed.Provides own ALS and NARCOTIC restock.Provides own OTC / First Aid Supply Restock
Check Types of Services Provided*

Line PersonnelREMS TeamsAmbulanceMedical Support TrailerMedical Module - EMTP/EMTB 4x4 Vehicle w/UTVInfectious Disease Isolation/TestingOther - Listed Below
List Other
Check Types of Personnel Provided*

RNLVNEMTPEMTBMAPA / MD / NPOther - Listed Below
List Other
National Registry ALONE is not a current license.

Each personnel MUST hold a current state license or state certification, from state in which business is licensed.
Do ALL Medical Personnel Hold a Current State License/Certification?
ACREDITATION

Please upload documentation of acreditation with a California LEMSA.

OR

RECIPROCITY

Please upload documentation of reciprocity authorization with a California LEMSA.
File Upload

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Should be Empty:

PROVIDER APPLICATION

ACREDITATION

OR

RECIPROCITY