Free Change of EMS Medical Director, DPH 7470 - Wisconsin

DEPARTMENT OF HEALTH & FAMILY SERVICES Division of Public Health DPH 7470 (07/03)

STATE OF WISCONSIN Chapters 110, 111, 112, 113, Wis. Admin. Code (608) 266-1568

For Office Use Only

CHANGE OF EMS MEDICAL DIRECTOR
This form is authorized under s. 146.50, Wisconsin Statutes and Chapters 110, 111 112 and 113, Wisconsin Administrative Code. Completion of this form is mandatory for a change of service medical director. Personally identifiable information requested on this form will be used for Bureau of EMS and Injury Prevention and licensure purposes only. INSTRUCTIONS: Type or print legibly.

MEDICAL DIRECTOR INFORMATION
Ambulance Service Provider Name (If more than one ambulance service is affected, submit a separate form per service.)

New Medical Director's Name

Wisconsin Medical License Number M.D. or D.O.

Address

Mailing Address (if different)

City

State

Zip Code

County

CPR Expiration Date Daytime Telephone Number

ACLS Expiration Date Pager Number

Date of Birth FAX Number

Gender Male Female E-mail Address

MEDICAL DIRECTOR CERTIFICATION
I acknowledge receipt of the Wisconsin Emergency Medical Services and Injury Prevention Handbook and have read the Chapter "Medical Program Director Roles and Responsibilities" in its entirety.

SIGNATURE ­ Medical Director

Date Signed

Return this document, a copy of your CPR and ACLS cards and a copy of your resume (curriculum vitae) to: DIVISION OF PUBLIC HEALTH BUREAU OF EMS & INJURY PREVENTION EMS Systems and Licensing Section PO Box 2659 Madison, WI 53701-2659