ࡱ> M =bjbj== "WW:$klhhh| 8 !<|YP #*(***..lH/8LLLL86M NN$Q /SOh/--@//O=**P===/8*h*L=/L==E:ZFPhG*# J)|4 :4F G)P0YPF S8SG=||MEDICAL COMMAND AUTHORIZATION FORM  FORMTEXT       FORMTEXT       FORMTEXT  ALS Service Affiliate #  FORMTEXT      Calendar Year  FORMTEXT     Last Name (ALS Practitioner) First MI FORMTEXT      Street Address FORMTEXT       FORMTEXT       FORMTEXT      City State Zip CodeE-mail Address:  FORMTEXT       Check One:  FORMCHECKBOX  EMT - Paramedic  FORMCHECKBOX  PHRN  FORMCHECKBOX  HP Physician  FORMCHECKBOX  Other  FORMTEXT       Department EMT-P / PHRN / HP #:  FORMTEXT       PHRN & Physicians OnlyPA License #:  FORMTEXT       Name of ALS Service:  FORMTEXT       License Expiration Date:  FORMTEXT       List all ambulance services with which you have had medical command authorization in the past five (5) years. If necessary, please use a separate sheet of paper. Name of Service  FORMTEXT       Dates with Service  FORMTEXT       ALS Service Medical Director  FORMTEXT       Telephone Number  FORMTEXT       Name of Service  FORMTEXT       Dates with Service  FORMTEXT       ALS Service Medical Director  FORMTEXT       Telephone Number  FORMTEXT       Name of Service  FORMTEXT       Dates with Service  FORMTEXT       ALS Service Medical Director  FORMTEXT       Telephone Number  FORMTEXT       Name of Service  FORMTEXT       Dates with Service  FORMTEXT       ALS Service Medical Director  FORMTEXT       Telephone Number  FORMTEXT       Name of Service  FORMTEXT       Dates with Service  FORMTEXT       ALS Service Medical Director  FORMTEXT       Telephone Number  FORMTEXT       Name of Service  FORMTEXT       Dates with Service  FORMTEXT       ALS Service Medical Director  FORMTEXT       Telephone Number  FORMTEXT       Has your medical command authorization ever been restricted? If yes, please provide a full description of each restriction on a separate sheet of paper, including name of ALS service and ALS service medical director.  FORMCHECKBOX  YES, Restricted for Initial Preceptoring  FORMCHECKBOX  YES, Restricted for Other Reason  FORMCHECKBOX  NO Has your medical command authorization ever been denied or withdrawn? If yes, please provide a full description of each denial or withdrawal on a separate sheet of paper, including name of ALS service and ALS service medical director.  FORMCHECKBOX  YES  FORMCHECKBOX  NO Has any disciplinary sanction been imposed against you (regardless of whatever it is presently stayed pending disposition of an appeal), or is any disciplinary charge currently pending against you? If yes, please explain on a separate sheet of paper.  FORMCHECKBOX  YES  FORMCHECKBOX  NO Please attach copies of the following:  FORMCHECKBOX  Current BCLS Course Completion  FORMCHECKBOX  Previous Years Continuing Education Record  FORMCHECKBOX  Pennsylvania Certification  FORMCHECKBOX  Pennsylvania License (Physician / PHRN)  FORMCHECKBOX  Attachments for Questions 1-4 (if applicable)I hereby certify that the information provided in this application is true and correct to the best of my knowledge, information, and belief. I grant the ALS service / medical director permission to investigate all information on this application, and grant third parties permission to release information about my professional competence to the ALS service / medical director. I understand that if my application is approved for medical command, this authorization will be valid for the current year, unless restricted or withdrawn by the ALS service / medical director. I further understand that if granted medical command authorization, it applies only to the ALS service listed on this application and only permits practice in accordance with the Statewide and regional medical treatment protocols.  FORMTEXT      Signature of ApplicantDate MEDICAL COMMAND AUTHORIZATION FORM  FORMTEXT       FORMTEXT       FORMTEXT  ALS Service Affiliate #  FORMTEXT      Calendar Year  FORMTEXT     Last Name (ALS Practitioner) First MI ALS Service Medical Director Checklist Initial Determination (Applicant has never had medical command authorization within PA). Must check each of the following:  FORMCHECKBOX  Verify continuing education requirements met.  FORMCHECKBOX  Verify certification through regional EMS council.  FORMCHECKBOX  Verify through regional EMS council that no disciplinary sanction is currently imposed against he individual that prevents the individual from receiving medical command authorization. Verification of competence to perform all services within the individuals scope of practice. Check at least one of the following:  FORMCHECKBOX  Direct observation  FORMCHECKBOX  Consult suitable physician, PHRN, or EMT-P who has directly observed performance of services Name:  FORMTEXT       Name:  FORMTEXT       Annual Review or Other Review with this ALS Service (Applicant has had previous medical command authorization within PA).  FORMCHECKBOX  Verify continuing education requirements met. Verification of competence to perform all services within the individuals scope of practice. Check at least one of the following:  FORMCHECKBOX  Direct observation  FORMCHECKBOX  Consult suitable physician(s), PHRN(s), or EMT-P(s) who directly observed performance of services Name:  FORMTEXT       Name:  FORMTEXT        FORMCHECKBOX  Perform medical audit of records of service.  FORMCHECKBOX  Consult emergency department physician(s) who has received patients treated by applicant. Name:  FORMTEXT       Name:  FORMTEXT        FORMCHECKBOX  Consult medical command physician(s) who has given command. Name:  FORMTEXT       Name:  FORMTEXT        FORMCHECKBOX  Consult ALS service medical director(s) who has granted, restricted, or denied medical command. Name:  FORMTEXT       Name:  FORMTEXT        Decision Rendered (Choose only ONE column)Initial (with any ALS service)  FORMCHECKBOX  Grant  FORMCHECKBOX  Restrict for Preceptoring  FORMCHECKBOX  Restrict for Other  FORMCHECKBOX  DenyInitial (with this ALS service)  FORMCHECKBOX  Grant  FORMCHECKBOX  Restrict for Preceptoring  FORMCHECKBOX  Restrict for Other  FORMCHECKBOX  DenyReview (annual or other)  FORMCHECKBOX  Renew  FORMCHECKBOX  Renew and Require Con. Ed.  FORMCHECKBOX  Restrict for Other  FORMCHECKBOX  Withdraw As the ALS service medical director of the referenced ambulance service, I have evaluated the individuals qualifications based upon the individuals ability to competently perform each of the services set forth within the scope of practice authorized by the individual s certification or recognition.  FORMTEXT  Dr. James S. Brady, MD FORMTEXT      ALS Service Medical Director (Printed)Signature of ALS Service Medical Director (Printed)Date RESTRICTION OR DENIAL OF MEDICAL COMMAND AUTHORIZATION  FORMTEXT       FORMTEXT       FORMTEXT  ALS Service Affiliate #  FORMTEXT      Calendar Year  FORMTEXT     Last Name (ALS Practitioner) First MI ACTION TAKENAs the ALS Service Medical Director for this ambulance service, I have taken the following action with respect to the practitioners medical command authorization with this ambulance service:  FORMCHECKBOX  RESTRICTED for Initial Service Preceptoring (This option may only be used if the applicant has NOT previously been granted medical command authorization with this service. This option may NOT be used if preceptoring is being done to remediate deficiencies.)  FORMCHECKBOX  RESTRICTED for Other Reason.  FORMCHECKBOX  RENEW AND REQUIRE REMEDIAL CONTINUING EDUCATION  FORMCHECKBOX  DENIED / WITHDRAWN List the restriction(s) placed on the medical command authorization or describe the reason for denial or withdrawal off medical command authorization:  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       If medical command authorization has been renewed and additional continuing education is required to address a demonstrated deficiency in competence, list the continuing education courses that must be successfully completed:  FORMTEXT        FORMTEXT        FORMTEXT         FORMCHECKBOX  The ALS practitioner has been notified of this decision and received a copy of this form.  FORMTEXT  Dr. James S. Brady, MDALS Service Medical Director (Print) FORMTEXT      ALS Service Medical Director (Signature)Date CERTIFICATIONS / CONTINUING EDUCATION Primary Certification ACLS Card BCLS Provider Card PALS Card BTLS Card ALS Preceptor PA Drivers License EVOC Certificate Annual Skills Review CertificateContinuing Education Summary Form EMSI  DOH Approved 9/12/02 Return completed copy to regional EMS council Page  PAGE 1 of  NUMPAGES 7 FH\^`jlnp0𾗒}m[SCJOJQJ\#j5CJOJQJUmHnHujH5CJOJQJU5CJOJQJj5CJOJQJUOJQJ CJOJQJj5CJOJQJUjj5CJOJQJUCJOJQJ\#j5CJOJQJUmHnHuj5CJOJQJU5CJOJQJj5CJOJQJUCJ Fn.0V $$Ifa$$If hpH@ABZx$If^Z hpH@ABHx$If^H B===02FHJRTVX  468BDFH\~n~^~j5CJOJQJUj5CJOJQJU#j5CJOJQJUmHnHuj5CJOJQJU5CJOJQJj5CJOJQJUOJQJ CJOJQJCJOJQJ\#j5CJOJQJUmHnHuj5CJOJQJU5CJOJQJj5CJOJQJU#VXm_YYY$If  !@ $If$$Ifl4ֈ  0*R ` `~ 4 laTZ@L  ! $If3$$Ifl40**4 la$Ifl$$Ifl4F\ 0**   ~ 4 laFnpoT_ ! 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