Free Ambulance Service Provider Application, DPH 7133 - Wisconsin

DEPARTMENT OF HEALTH & FAMILY SERVICES Division of Public Health DPH 7133 (Rev. 04/03)

STATE OF WISCONSIN s. 146.50 Wis. Stats. (608) 266-1568

AMBULANCE SERVICE PROVIDER LICENSE APPLICATION
This form is authorized under s.146.50, Wisconsin Statutes and Chapters HFS 110, 111 and 112, Wisconsin Administrative Code. Completion of this form is mandatory for licensure as an ambulance service provider. Personally identifiable information requested on this form will only be used for licensure purposes. INSTRUCTIONS: Type or print legibly. Complete all sections of the form. Failure to complete all required sections of this form and submit required materials will result in the application being returned unprocessed. DIVISION OF PUBLIC HEALTH BUREAU OF EMERGENCY MEDICAL SERVICES & INJURY PREVENTION P.O. BOX 2659 MADISON, WI 53701-2659 For Office Use Only

RETURN COMPLETED FORM TO:

SERVICE INFORMATION
Type of application - check one: c Initial c Change of Ownership c Change of License Level Provider License Number

Name of Service Street Address (where records are kept) City State Zip Code County Non-Emergency Phone Number

Mailing Address (if different than above) City FEIN Number CLIA Number State Zip Code E-mail Address

OWNER INFORMATION
Owner's Name Street Address City State P O Box Zip Telephone Number ( ) E-mail Address P O Box State Zip Telephone Number ( ) E-mail Address

DIRECTOR/OPERATOR INFORMATION
Director/Operator Name Street Address City

LICENSE LEVEL ­ Please check your service's license level (check all that apply)
EMT-Basic EMT-Basic IV Tech EMT-Intermediate EMT-Paramedic

TYPE OF OWNERSHIP (check one)
Private Non-Profit Private For Profit Municipal

SIGNATURE ­ Applicant (Owner or Operator)

Date Signed

Application is not complete unless accompanied by EMS Ambulance Operational Plan or applicable changes to the EMS Ambulance Operational Plan.