Regional ALS Agency Application

STEP 1: Complete the electronic form below.

STEP 2: Submit the following accompanying documents via email to thowe@mountainlakesems.org. If necessary, you may also fax to (518) 793-5833 or mail to Mountain Lakes Regional EMS Council, 375 Bay Road, STE 202, Queensbury, NY 12804.

 

Agency ALS Application

Upon completion of the following fields and hitting the send button, your online application will be emailed directly to the Mountain Lakes office.

*Required
*Reason for Application Submission:
*Legal Name of Agency (include any dba):

*Name(s) of Agency Individual Owner, Partners or Government Entity:
*NYS DOH BEMSTS Agency Code:

*Employee ID #:
*Agency Mailing Address:

*Agency Physical Address (headquarters if multiple locations):
*Email Address:

*Current Service Type:
*Current Approved Level of Service:

*Level of Service You Are Applying For:
*Name of 911 Dispatch Service (County or Entity):

*Name of QA/QI Group or List of Participating Agencies:
*Does Your Agency Bill for Services?:

*List All Agency Vehicles (include make, model, year, ALS or BLS and function):
*Describe the structure of your coverage schedule. What members (including level of care) are scheduled to respond to EMS calls on a 24/7 basis? Also, if your agency is using tools such as I am Responding, please indicate this in your response.:

*Describe how components of your agency are dispatched to emergency calls in a timely manner. When your agency’s members are on duty do they reside in the building or do they respond from home?:
*How do you meet the REMAC mandate of having a minimum of a BLS ambulance en-route to calls within 10 minutes of the call being received, 75% of the time (include any data you have available and email attachments if necessary?):

*If there are times when you do not have a crew scheduled to cover your territory, what arrangements have you made to cover calls? If there are response delays due to schedule holes, what steps are being taken to correct this?:
*In general, how will your agency improve on its ability to provide 24/7 ALS coverage? Briefly describe recruiting, training and other initiatives in place to improve or maintain ALS coverage.:

*Describe the structure and functionality of your QA/QI program/initiatives (must meet or exceed REMAC and NYS requirements.) Also, please give the name of your QA/QI group, names of group members and an overview of activities for the past year.: