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Applications & Forms

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Ambulance Vehicle Operators Course (AVOC)

• Ambulance Vehicle Operators Course Application Form (PDF)

Clia Waiver Form and Instructions

• CLIA Waiver Application Instructions (PDF)
• CLIA Waiver Application Form (Link)

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Provider License Applications

Applications for a "New" Provider License

• EMS Provider, Emergency Medical Dispatcher & Instructor Coordinator "New" License Application (PDF) - Revised May 1, 2013
• Flight Nurse Application

License Renewal Application

• EMS, EMD & IC Personnel "Renewal" License Application (PDF) - Not applicable to licenses expired over 90 days.
• EMD License Renewal Information (PDF)

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Reciprocity License Application

• EMS Reciprocity Application (PDF) - Revised May 1, 2013

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EMS Service & EMD Center Forms

• EMS Service Change in Administration Form (PDF)
• EMS Service License [new] (PDF)
• EMS Service License [renewal] (PDF)
• EMS Vehicle Authorization Form (PDF) - Revised June 8, 2012
• Emergency Medical Dispatch Center License Application (PDF)
  
• Epinephrine Autoinjector Application Packet (PDF)
• Maine EMS Inspection Form - Updated April 24, 2013(PDF) By request, we have made the MEMS inspection form available here for downloading. This is the form used during the annual ambulance and first responder inspections. For a full description of all required equipment, please see Chapter 17 of the Maine EMS Rules.

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Paramedic Interfacility Transfer (PIFT) Forms

• Paramedic Interfacility Transfer (PIFT) Course Application for Instructors (PDF)
• PIFT Service Application (PDF)

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Quality Assurance Forms

• 12 Lead Electrocardiogram (EKG) Quality Improvement Form (PDF)
• Airway Quality Improvement Form (PDF)
• PIFT QA Form (PDF)
• Spinal Assessment Training Quality Assurance Form (PDF)

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Do Not Resuscitate (DNR) Forms

The Maine EMS Comfort Care/DNR program has two different forms available, depending upon whether the patient has the capacity to make an informed decision.

The Comfort Care/DNR Directive is available for use by anyone over 18 years of age who is capable of making an informed decision. By completing the form, the person named on the form is directing EMS crews to not attempt resuscitation if the person’s heart or breathing stops. The Comfort Care/DNR Directive form must be signed by a licensed physician, who attests that the person has the mental capacity to make an informed decision concerning DNR. A physician is under no obligation to sign the Comfort Care/DNR Directive form, but may do so if requested by the person whose name appears on the form.

The Comfort Care/DNR Order is used when the person named on the form does not have the capacity to make an informed decision (e.g., guardianship, surrogate). When completed and signed by the patient’s physician and guardian/surrogate, the form documents a physician order to withhold resuscitation.

• Comfort Care/DNR Directive (PDF)
• Comfort Care/DNR Order (PDF)
• Comfort Care/DNR Physician Instructions (PDF)

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