BLS Ambulance Service Medical Directors Agreement: Fill out & sign online

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Click ‘Get Form’ to open the BLS Ambulance Service Medical Directors Agreement in the editor.
Begin by entering the 'Service Name' and 'AFFILIATE #' at the top of the form. Ensure these details are accurate as they identify your service.
In the 'Qualifications' section, confirm that you hold a valid physician license in Pennsylvania and possess a DEA number. If applicable, indicate your completion of a residency program in emergency medicine or ACLS certification.
Review and check off each responsibility listed under 'Responsibilities'. This includes providing medical direction and participating in quality improvement activities.
Sign and print your name in the designated fields, along with your medical license number and DEA number. Ensure all information is correct before finalizing.
Fill out your mailing address, including city, state, and zip code, to ensure proper communication regarding this agreement.

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