Pa Medical Command Authorization Form PDF Details

In the realm of emergency medical services (EMS), stringent protocols ensure that individuals providing Advanced Life Support (ALS) meet specific qualifications and standards. At the heart of these protocols in Pennsylvania is the Medical Command Authorization Form, a meticulously designed document that encapsulates the essence of regulatory oversight and professional accountability. This form is utilized by ALS providers, including EMT-Paramedics, Pre-Hospital Registered Nurses (PHRN), and physicians, as part of the process to gain or renew authorization to perform ALS services under the guidance of a medical command. It requires detailed information from applicants, such as their affiliation with ALS services, personal identification, professional qualifications, and a comprehensive history of medical command authorizations, restrictions, or denials, if any. The form also mandates the disclosure of any past disciplinary actions against the applicant and provides a checklist for the ALS Service Medical Director to verify the applicant’s continuing education, certification status, and competence. Additionally, it outlines procedures for addressing restrictions or denials of medical command authorization, ensuring that ALS providers meet the rigorous standards necessary for delivering critical care in emergency situations. By encapsulating these key aspects, the form serves as an essential tool for maintaining the high quality of emergency medical care in Pennsylvania.

QuestionAnswer
Form NamePa Medical Command Authorization Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other nameseastern pa medical command forms, pennsylvania medical command form, eastern pa medical command form, pa medical command authorization form

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MEDICAL COMMAND AUTHORIZATION FORM

ALS Service Affiliate #

Calendar Year

Last Name (ALS Provider)

First

 

MI

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

State

Zip Code

 

 

 

 

 

 

 

 

E-mail Address

 

 

 

 

 

 

 

Check One:

EMT-Paramedic

 

PHRN

HP Physician

Other______________________

Department EMT-P / PHRN / HP #:___________________

Name of ALS Service:_____________________________

PHRN & Physicians Only

PA License #:_________________________________

License Expiration Date:

1.List ALL ambulance services with which you have had medical command authorization in the past five years. If necessary, please use a separate sheet of paper.

Name of Service________________________________

Dates with Service_______________________________

ALS Service Medical Director______________________

Telephone Number______________________________

Name of Service________________________________

Dates with Service_______________________________

ALS Service Medical Director______________________

Telephone Number______________________________

Name of Service________________________________

Dates with Service_______________________________

ALS Service Medical Director______________________

Telephone Number______________________________

Name of Service________________________________

Dates with Service_______________________________

ALS Service Medical Director______________________

Telephone Number______________________________

Name of Service________________________________

Dates with Service_______________________________

ALS Service Medical Director______________________

Telephone Number______________________________

Name of Service________________________________

Dates with Service_______________________________

ALS Service Medical Director______________________

Telephone Number

2.Has your medical command authorization ever been restricted? If yes, please provide a full description of each restriction on a separate sheet of paper, including name of ALS service and ALS service medical director.

YES, Restricted for Initial Preceptoring

YES, Restricted for Other Reason

NO

3.Has your medical command authorization ever been denied or withdrawn? If yes, please provide a full description of each denial or withdrawal on a separate sheet of paper, including name of ALS service and ALS service medical director.

YES NO

4.Has any disciplinary sanction been imposed against you (regardless of whether it is presently stayed pending disposition of an appeal), or is any disciplinary charge currently pending against you? If yes, please explain on a separate sheet of paper.

YES NO

Please attach copies of the following:

Current BCLS Course Completion

Previous Year’s Continuing Education Record

Pennsylvania Certification

Pennsylvania License (Physician/PHRN)

Attachments For Questions 1-4 (If Applicable)

I hereby certify that the information provided in this application is true and correct to the best of my knowledge, information, and belief. I grant the ALS service/ medical director permission to investigate all information on this application, and I grant third parties permission to release information about my professional competence to the ALS service/ medical director. I understand that if my application is approved for medical command, this authorization will be valid for the current calendar year, unless restricted or withdrawn by the ALS service medical director. I further understand that if granted medical command authorization, it applies only to the ALS service listed on this application and only permits practice in accordance with the Statewide and regional medical treatment protocols.

Signature of Applicant

 

Date

S:\MEDICAL COMMAND\MEDCOMMAUTHFORM

1

04/24/2013

MEDICAL COMMAND AUTHORIZATION FORM

ALS Service Affiliate #

Calendar Year

Last Name (ALS Provider)

First

MI

ALS Service Medical Director Checklist

Initial Determination (Applicant has never had medical command authorization within PA).

Must check each of the following.

Verify continuing education requirements met

Verify certification through regional EMS council

Verify through regional EMS council that no disciplinary sanction is currently imposed against the individual that prevents the individual from receiving medical command authorization

Verification of competence to perform each of the services within the individual’s scope of practice. Check

at least one of the following:

Direct observation

Consult suitable physician, PHRN, or EMT-P who has directly observed performance of services

Name:_________________________________

Name:_________________________________

Annual Review or Other Review with this ALS Service (Applicant has had previous medical command authorization within PA).

Verify continuing education requirements met

Verification of competence to perform each of the services within the individual’s scope of practice. Check

at least one of the following:

Direct observation

Consult suitable physician(s), PHRN(s), or EMT-P(s) who directly observed performance of services.

Name:_________________________________

Name:_________________________________

Perform medical audit of records of service

Consult emergency department physician(s) who has received patients treated by applicant

Name:_________________________________

Name:_________________________________

Consult medical command physician(s) who has given command

Name:_________________________________

Name:_________________________________

Consult ALS service medical director(s) who has granted, restricted, or denied command

Name:_________________________________

Name:

Decision Rendered (Choose Only One Column)

Initial (with any ALS service)

Initial (with this ALS service)

Review (annual or other)

Grant

Grant

Renew

Restrict for Preceptoring

Restrict for Preceptoring

Renew and Require Con. Ed.

Restrict for Other

Restrict for Other

Restrict for Other

Deny

Deny

Withdraw

As the ALS service medical director of the referenced ambulance service, I have evaluated the individual’s qualifications based upon the individual’s ability to competently perform each of the services set forth within the scope of practice authorized by the individual’s certification or recognition.

ALS Service Medical Director (Printed)

Signature of ALS Service Medical Director

Date

_________________________________________

____________________________________

_____________

ALS Provider (Printed)

Signature of ALS Provider

Date

S:\MEDICAL COMMAND\MEDCOMMAUTHFORM

2

04/24/2013

RESTRICTION OR DENIAL OF MEDICAL COMMAND AUTHORIZATION

ALS Service Affiliate #

Calendar Year

Last Name (ALS Provider) First

MI

ACTION TAKEN

As the ALS service medical director for this ambulance service, I have taken the following action with respect to the practitioner’s medical command authorization with this ambulance service:

RESTRICTED for Initial Service Preceptoring (This option may only be used if the applicant has not previously been granted medical command authorization with this service. This option may not be used if preceptoring is being done to remediate deficiencies.)

RESTRICTED for Other Reason

RENEW AND REQUIRE REMEDIAL CONTINUING EDUCATION

DENIED / WITHDRAWN

List the restriction(s) placed on the medical command authorization or describe the reasons for denial

or withdrawal of medical command authorization:

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

If medical command authorization has been renewed and additional continuing education is required

to address a demonstrated deficiency in competence, list the continuing education courses that must

be successfully completed:

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

The ALS practitioner has been notified of this decision and received a copy of this form.

___________________________________

____________________________________________

___________

ALS Service Medical Director (Print)

Director (Signature)

Date

_____________________________

____________________________________

_________

ALS Provider (Print)

ALS Provider (Signature)

Date

S:\MEDICAL COMMAND\MEDCOMMAUTHFORM

3

04/24/2013

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