Apply to operate a Community EMS Program

The Community EMS application form must be completed by a local public health authority (such as a board of health) in partnership with the primary ambulance service in the local jurisdiction where the proposed Community EMS Program will operate.

• The application must be received by DPH at least 30 calendar days prior to the proposed start of Community EMS Program operations.
• The application is posted as a fillable PDF.  You will need to have either Adobe Acrobat or Adobe Reader installed on your computer to complete the application forms. 
• When you open the application, please download and save it to your computer before filling it out. If you fill out the application in your Internet browser without saving, all changes will be lost once the browser window is closed.
• The application allows applicants to use an electronic signature. Please note that handwritten documents and attachments will not be accepted. If you need assistance setting up your electronic signature, please see the Instructions to create an electronic signature.

Application Requirements

A complete Community EMS application includes:

• Completed application form l (Word), including all required attachments, descriptions, and narratives
• Letter of support from the authorized signatory of the local jurisdiction, if signature on the application could not be completed (submission should be on official letterhead of jurisdiction)

Applicants who wish to propose adding a service to the Defined List of Community EMS Program Services must submit a petition form l (Word) to DPH for consideration.