Forms

All forms can completed by tabbing through the various fields to be filled out, and then printed.

NDP EMS Forms:
Medical Release Form

PCS (Physician Certification Form) Transport Request

Insurance Request Form

New York Motor Vehicle No-Fault Insurance Law Assignment of Benefits Form

Charity Care Application

Request For Workers Compensation Information

Regional Forms:

Hudson Valley regional EMS Council Continuing Education Verification Form

State Forms:

NYS Department of Health Verification of Membership in a NYS EMS Agency
(NYS EMT or NYS CFR classes) (NYS DOH – 3312)

NYS Department of Health Application for Emergency Medical Services Certification
(NYS EMT or NYS CFR Classes) (NYS DOH – 65)

NYS Department of Health CME-Based Recertification Pilot Program – EMT-Basic
(NYS DOH – 4228 7/03)

NYS Department of Health CME-Based Recertification Pilot Program – EMT-P
(NYS DOH – 4231 7/03)

NYS Department of Health Participant Registration Form (CME Recert Program)
(NYS DOH – 4226 7/03)