• EMS Medical Control Application

  • Demographics

  • Format: (000) 000-0000.
  • Expiration Date*
     - -

  • Employer Information

  • Application Type*

  • Background and History

  • Have you ever been named a party in a medical malpractice suit?*
  • Have you ever been denied medical control authorization as an ALS or BLS provider?*
  • Have you ever had medical control authorization restricted in any manner, suspended, revoked or placed on probation?*
  • Do you currently have any open investigations into your authorization to practice?*
  • Have you ever had your state DPH-OEMS certificate suspended or revoked?*

  • EMS Medical Control Good Standing

  • If you are a:

    • Brand New EMT: list your EMT program director
    • Brand New Paramedic: list your medical director or EMS coordinator where you were an EMT
    • Experienced EMT: list your previous medical director or EMS coordinator 
    • Experienced Paramedic: list your previous medical director or EMS coordinator 

  • Attestation

  • I hereby apply for medical control authorization under the Mercy Medical Center Affiliated Medical Director of Emergency Medical Services. I, the undersigned, declare the information provided herein is both accurate and truthful and I understand that any incorrect statement or omissions may be the basis for my disqualification for, or revocation of medical control authorization. I hereby grant authority to Mercy Medical Center Affiliated Medical Director of Emergency Medical Services, or his/her designee to request records of past employment, training and personal background as applicable to medical control authorization from the hiring agency. This document serves as a release to any company, agency, or entity to release these records to the Mercy Medical Center Affiliated Medical Director of Emergency Medical Services. I also agree to follow all applicable guidelines, policies, procedures and protocols appropriate for my level of authorization to practice.

  • Should be Empty: