EMS Provider Licensing

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SURVEY REQUEST
In order to serve you better, DSHS would like you to complete a short online survey at: https://reglicensing.questionpro.com. The information you provide will assist DSHS in its efforts to continually improve and become more responsive to the needs of its customers. Thank you in advance for your cooperation.


First Responder Registration information


Guidance Regarding the Renewal of an EMS Provider License

Update to Medicaid Surety Bonds for Ambulance Providers


Provider Licensing Rule
Regional Office Contact Information

EMS Provider Licensing Forms: 

EMS Provider Application
EMS Provider Declaration Form
Administrator of Record
EMS Personnel Form
EMS Vehicle Form
Medical Director Form
Notifications / Changes Form
Replacement License / Authorization Form
EMS Station Location List

Online Provider Licensing (Renewal Only):

Renewal Provider


EMS Provider Licensing Checklists

Use the following checklist as a guide regarding required documentation and elaboration of each provider licensing requirement.
EMS Provider Licensing Checklist - Initial License
EMS Provider Licensing Checklist - Renewal License
EMSProvider Licensing Site-Survey Checklist

PLEASE USE THE BELOW LISTED COVER SHEETS WHEN SUBMITTING FRO FEES AND/OR DOCUMENTATION

PLEASE NOTE THAT MONEY MAIL IS TO BE SUBMITTED TO A DIFFERENT ADDRESS THAN SUBMITTALS WITHOUT PAYMENT

Mailed Fee Payments

Use/Submit the below linked cover sheet and address for mailed fee payments:
Cover Sheet - Mailed Documents Containing Fee Payments

Use/Submit the below linked cover sheet and address for mailed fee payments:

Overnight Delivery, Etc. with Fee Payments

Use/Submit the below linked cover sheet and address for overnight delivery(or parcels or express) with fee payments:
Cover Sheet - Overnighted Documents Containing Fee Payments

Use/Submit the below linked cover sheet and address for overnight delivery(or parcels or express) with fee payments:

Any Submission With No Fee

Use one of the links below for the appropriate cover sheet and address for any submission with no fee payment:
Cover Sheet - General mail with no fee payments
Cover Sheet - Overnighted mail with no fee payments

 


 

For help or questions about EMS Provider forms or processing contact EMS Compliance Staff at 512/834-6700 – Christopher Meyer – Extension 2317 or Denny Martin - Extension 2373

For help or questions about EMS First Responder forms or processing contact Daniel Williams at 512/834-6700 – Extension 2329

For technical assistance contact your local field office you can find a list of offices at: Regional Office Contact Information

 

 

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Last updated April 10, 2014