Medical Transportation

Medical Transportation Checklists & Forms

The way you apply for, renew, and manage your medical transportation license has changed.

A new online system has been developed called MTLS Online. We will no longer accept paper applications and forms. All fees must be paid via credit card or Automated Clearing House (ACH).

To register with Identity Manager or log into the MTLS Online System use the following link: https://services.dps.ohio.gov/EMSMTLS.

CLICK HERE for help registering and navigating in the new system.

Inspection Forms

The following inspection forms are provided to assist you in preparing for your inspection. They are the same forms the inspector will use during the inspection.

Ambulance
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
Non-transport Vehicle Inspection EMS 4026 PDF Word
Periodic Mechanical Safety Report EMS 4039 PDF Word
Ambulette
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
Ambulette Employee Files EMS 4044 PDF Word
Periodic Mechanical Safety Report EMS 4039 PDF Word
MoICU
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
Non-Transport Vehicle Inspection EMS 4026 PDF Word
Periodic Mechanical Safety Report EMS 4039 PDF Word
Air Service
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

Sample Only Forms

The following forms are for reference only. The functions of each of these forms is no longer done on paper but through the MTLS Online System. To register with Identity Manager or log into the MTLS Online System, use the following link: https://services.dps.ohio.gov/EMSMTLS.

CLICK HERE for help registering and navigating in the new system.

Ambulance / MoICU
Application for Ambulance or Mobile Intensive Care License EMS 4001 PDF
Additional Ambulance / MOICU / Non-Transport Vehicle EMS 4006 PDF
Deletion of Ambulance EMS 4012 PDF
Headquarters Change of Address EMS 4004 PDF
Application for New Satellite EMS 4005 PDF
Temporary Ambulance / MoICU / Non-Transport Vehicle EMS 4009 PDF
Change in Level of Service Medical Transportation Organization EMS 4011 PDF
Renewal Application for Ambulance or Mobile Intensive Care EMS 4040 PDF
Ambulette
Application for Ambulette License EMS 4002 PDF
Additional Ambulette EMS 4007 PDF
Temporary Ambulette Application EMS 4010 PDF
Renewal Application for Ambulette License EMS 4041 PDF
Air Medical
Application for Air Medical License EMS 4003 PDF
Additional Aircraft EMS 4008 PDF
Deletion of Aircraft EMS 4013 PDF
Temporary Aircraft EMS 4046 PDF
Renewal Application for Air Medical License EMS 4042 PDF
Violation Notification
Violation Notification EMS 4029 PDF

Complaint Form 

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

Medical Transportation Additional Resources

Ambulette Employee Physician Statement Resource   PDF
Daily Vehicle Inspection Log Resource   PDF

 

Have Questions?

Email the Medical Transportation Section

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

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