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Massachusetts 500 1 part a

Massachusetts 500 1 part a 2026

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The document is an application form for ambulance service licensing from the Massachusetts Department of Public Health's Office of Emergency Medical Services. It includes sections for service information, licensee details, ownership type, staffing levels, and compliance with non-discrimination and tax certification requirements. The form also outlines fees associated with different levels of service licenses and provides instructions for submission.

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Click ‘Get Form’ to open the Massachusetts 500 1 Part A application in the editor.
Begin by entering the Service Number and Service Expiration Date at the top of the form. Select whether this is an Initial, Renewal, or Modification application.
In the SERVICE INFORMATION section, fill in your service's Name, Address, City, State, Business Phone Number, Manager Name, and Email address. Ensure all contact details are accurate for effective communication.
Proceed to LICENSEE INFORMATION and provide similar details for the licensee. Include a 24 Hour Access Number and Fax Number if applicable.
Indicate your Service Ownership Type (e.g., Sole Proprietor, Corporation) and answer whether you hold other valid licenses in Massachusetts.
Complete sections regarding your Level of License applying for and affiliations with hospitals. Fill in vehicle counts and staffing information as required.
Finally, review the STATEMENT OF NON-DISCRIMINATION and TAX CERTIFICATION STATEMENT sections before signing and dating the application.

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