Legal Scope & Service Authorization Intake

Legal Scope & Service Authorization Intake

Complete this screening form to request EMS/medical standby and consulting services and authorize review of your event details, conflicts, and scope limitations.
Client & Organization Identification
Legal Name

First NameMiddle NameLast Name
Preferred Contact Name
Organization Type
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Business or Agency Identifier
Request Summary & Event/Agency Details
Requested Service Track

Other
Event or Agency Name
Event Type / Department Type
Brief Description of the Request
Date of Service

MonthDayYear
Date
Start Time

Hour Minutes

AM/PM Option
End Time / Service Window End

Hour Minutes

AM/PM Option
Venue / On-Site Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Expected Attendance / Staff Size
Venue Access Details and Operational Notes
Lead Source & Conflict Screening
Lead Source
Do you have any current employment that may relate to this matter?
Describe any current employment, including employer name and any potential relationship to this matter
Describe any former employment, related organization ties, or other conflicts that may affect acceptance or scope
Requested Clinical/Operational Expectations
Requested clinical/operational expectations

Other
Operational support needs

Other
Additional expectations or requested deliverables
Existing Coverage, Access & Risk Factors
Does the venue or event already have existing medical coverage in place?
Is an AED available on site?
Please describe any venue access constraints or special entry instructions.
Select any event hazards or special conditions that may apply.

Other
Describe any risk controls or mitigation measures already planned.
Provide any additional details about access, hazards, or special conditions relevant to medical response.
Consulting Scope Requests
Consulting request areas

Other
Priority needs and expected deliverables
Target timelines and milestone dates
Internal governance, review, or approval requirements
Additional notes or special instructions
Scope, Limitations & Authorization
Authorized Signer Name

First NameMiddle NameLast Name
Signature & Date
Printed Name

First NameLast Name
Title / Role
Signature
Date Signed

MonthDayYear
Date
Should be Empty:

Legal Scope & Service Authorization Intake

Client & Organization Identification

Request Summary & Event/Agency Details

Lead Source & Conflict Screening

Requested Clinical/Operational Expectations

Existing Coverage, Access & Risk Factors

Consulting Scope Requests

Scope, Limitations & Authorization

Signature & Date