Pa Medical Command Authorization Form – Fill Out and Use This PDF

The Pa Medical Command Authorization Form is an official document that allows access to special permissions related to Pennsylvania's military medical operations. It helps prove authorization to enable the requesting individual to move within the ranks of the state's military medical command structure. The form was created by an executive looking for more secure verification that individuals had authority and access rights for these scenarios. Working in conjunction with other participating healthcare facilities, it provides safe and reliable documentation that commands are occupying exclusive hospitals and dealing with emergencies as they arise. Furthermore, this authorization ensures a uniform level of compliance across all of Pennsylvania's established medical tasks and reinforces necessary procedures for high profile critical care environments.

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Pa Medical Command Authorization Form PDF Details

Are you a service member or veteran needing to access medical care at one of the three federal medical facilities in Pennsylvania? If so, you will need to complete and submit a Pennsylvania Medical Command Authorization Form. This form provides your relevant information and authorization needed for evaluation, diagnosis, and treatment by a doctor or hospital at any of the three U.S. military clinics located in region. In this blog post, we're going over all that you need to know about completing this important document - from what documents are needed along with it to where and how it should be submitted. So keep reading if you want an easy-to-follow guide on making sure your PA Medical Command Authorization is processed quickly and efficiently!

Question	Answer
Form Name	Pa Medical Command Authorization Form
Form Length	3 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	45 sec
Other names	eastern 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
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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Best ways to fill in eastern pa medical command form stage 1

2. Given that this segment is completed, you're ready to insert the required details in Name of Service Dates with Service, Name of Service Dates with Service, Name of Service Dates with Service, Name of Service Dates with Service, been denied or withdrawn If yes, YES NO Has any disciplinary, against you regardless of whether, YES NO, Please attach copies of the, and I hereby certify that the so you're able to proceed to the 3rd part.

Name of Service Dates with Service, Name of Service Dates with Service, and Name of Service Dates with Service of eastern pa medical command form

3. Throughout this part, have a look at Last Name ALS Provider, ALS Service Affiliate, Calendar Year, First, ALS Service Medical Director, Initial Determination Applicant, Verify continuing education, Verify through regional EMS, Annual Review or Other Review with, Verify continuing education, Verification of competence to, Direct observation, Consult suitable physicians PHRNs, and Name Name. Each one of these have to be completed with highest precision.

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4. To move ahead, this next form section involves completing several empty form fields. Included in these are Direct observation, Consult suitable physician PHRN, Name Name, Name Name, Perform medical audit of records, Consult emergency department, Name Name, Consult medical command, Name Name, Consult ALS service medical, Name, Name, and Decision Rendered Choose Only One, which are vital to going forward with this particular PDF.

Decision Rendered Choose Only One, Consult emergency department, and Name Name of eastern pa medical command form

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5. Because you draw near to the last parts of your file, you'll notice just a few more requirements that have to be met. Specifically, Initial with any ALS service, As the ALS service medical, Signature of ALS Service Medical, Signature of ALS Provider, Date, Date, and SMedical CommandMedCommAuthform must all be filled in.

Writing segment 5 in eastern pa medical command form

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