Medical Transportation

Medical Transportation Checklists & Forms

Ambulance

License Application Checklist EMS 4028 PDF Word
Application for Ambulance or Mobile Intensive Care License EMS 4001 PDF Word
Headquarters Facility Inspection Emergency Medical Service EMS 4014 PDF Word
Ambulance Inspection EMS 4016 PDF Word
Satellite Facility Inspection Emergency Medical Service EMS 4015 PDF Word
Additional Ambulance / MOICU / Non-Transport Vehicle EMS 4006 PDF Word
Deletion of Ambulance EMS 4012 PDF Word
Non-transport Vehicle Inspection EMS 4026 PDF Word
Headquarters Change of Address EMS 4004 PDF Word
Application for New Satellite EMS 4005 PDF Word
Temporary Ambulance / MoICU / Non-Transport Vehicle EMS 4009 PDF Word
Change in Level of Service Medical Transportation Organization EMS 4011 PDF Word

Ambulette

License Application Checklist EMS 4028 PDF Word
Application for Ambulette License EMS 4002 PDF Word
Headquarters Facility Inspection Non-Emergency Medical Service EMS 4017 PDF Word
Ambulette Inspection EMS 4019 PDF Word
Satellite Facility Inspection Non-Emergency Medical Service EMS 4018 PDF Word
Additional Ambulette EMS 4007 PDF Word
Deletion of Ambulette EMS 4012 PDF Word
Headquarters Change of Address EMS 4004 PDF Word
Application for New Satellite EMS 4005 PDF Word
Temporary Ambulette Application EMS 4010 PDF Word
Ambulette Employee Files EMS 4044 PDF Word

MoICU

License Application Checklist EMS 4028 PDF Word
Application for Ambulance or Mobile Intensive Care License EMS 4001 PDF Word
Headquarters Facility Inspection Mobile Intensive Care Service EMS 4020 PDF Word
MoICU Inspection EMS 4022 PDF Word
Satellite Facility Inspection Mobile Intensive Care Service EMS 4021 PDF Word
Additional MoICU / Non Transport Vehicle EMS 4006 PDF Word
Deletion of MoICU EMS 4012 PDF Word
Non-Transport Vehicle Inspection EMS 4026 PDF Word
Headquarters Change of Address EMS 4004 PDF Word
Application for New Satellite EMS 4005 PDF Word
Temporary Ambulance / MOICU / Non-Transport Vehicle EMS 4009 PDF Word
Change in Level of Service Medical Transportation Organization EMS 4011 PDF Word

Air Service

License Application Checklist EMS 4028 PDF Word
Application for Air Medical License EMS 4003 PDF Word
Headquarters Facility Inspection Air Medical Service EMS 4023 PDF Word
Aircraft Inspection EMS 4025 PDF Word
Satellite Facility Inspection Air Medical Service EMS 4024 PDF Word
Additional Aircraft EMS 4008 PDF Word
Deletion of Aircraft EMS 4013 PDF Word
Headquarters Change of Address EMS 4004 PDF Word
Application for New Satellite EMS 4005 PDF Word

Sample Only Forms

Periodic Mechanical Safety Report EMS 4039 PDF
Renewal Application for Ambulance or Mobile Intensive Care EMS 4040 PDF
Renewal Application for Ambulette License EMS 4041 PDF
Renewal Application for Air Medical License EMS 4042 PDF
Violation Notification EMS 4029 PDF

Miscellaneous 

Complaint Form for EMS, Fire or Medical Transportation EMS 0050 PDF Word

 

Have Questions?

Email the Medical Transportation Section

Or call us at
(614) 466-9447 or (800) 233-0785