Please contact the Division at 217-785-2080 or at DPH.EMTLIC@illinois.gov with questions or for more information. An individual can change their name with IDPH by emailing their EMS System a copy of their marriage license, divorce decree (front page and name change page only), or court order. Injury and Illness Report - PDF
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settings Services account_balance Agencies supervised_user_circle Social. Much of the Illinois EMS licensing process can be accomplished online, using the links and forms available on this page. 0000003055 00000 n
Enter your new address. 0000001009 00000 n
Form, Lead Risk Evaluation and Blood Lead Testing Guidelines, Lead Risk Assessment Questionnaire, Medical Childhood, Lead Supervisor, Inspector, Risk
PDF
Remember, you will not be allowed to function as an EMS provider until you have in your possession the new EMT-B license. Lead Training Course Application - PDF - Instructions
If so, what system number? 0000026303 00000 n
Local Education Agencies for, Asbestos Training Courses, List of Illinois
5 26
EMS System Application Instruction Guide Independent EMS License Renewal Request Form - PDF Reasonable Accommodation Request for Examinees with Disabilities - Fillable PDF Renewal Notice - PDF Request for Duplicate License Certificate - Fillable PDF Stretcher Van Inspection Form - Fillable PDF Trauma Nurse Specialist (TNS) Examination Application Home Health, Home Services, Home Nursing and Placement
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Facility Information Change Form - Fillable PDF*
Instrument Dispenser License Correction Form - PDF, [New Combined Home Health, Home Services, Home Nursing and Placement Agency Initial Application is now available. STEP 2: Contact the LEMSS office To notify the System of your address change. 0000075240 00000 n
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As designated by code, the Iowa Department of Public Health is the lead agency responsible for the development, implementation, coordination and evaluation of Iowa's EMS system. Last 4 digits of SSN
Instrument Dispenser Inactive Status Request Form, Hearing
License Information License Application Forms Notice Resources & Publications Laws and Rules Contact Us Code Book Order Form - PDF
PDF, Affidavit of No Employees - PDF
Facility Medicare Certification - PDF
Accredited - PDF, Asbestos Training Course Instructor Application - PDF, Asbestos Training Course Provider
Contractor Application - PDF -
Agency Licensing Renewal/Change of Ownership Application, Home Health
Application - PDF
Request for Manufactured Home Installation Seals and Certificates
Application, Apprentice, Plumber's
Instructions, Asbestos Worker Application
Information Change Form - Fillable PDF*
Gestational Surrogate's Husband - PDF
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"`^. from The Hill: The labor board is not the only . Agency Licensing Renewal/Change of Ownership Application - Fillable PDF*
Vision Screening Worksheet -
Request for Duplicate License Certificate - Fillable PDF
Biological Father Affidavit
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Birth Parent Registration Forms
Birth Record Files of a Deceased Infant, Application for Search of - Fillable PDF*
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Warning: You don't need to pay a separate company to change your address. endstream
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payable to the Illinois Department of Public Health. *These are draft forms pending final approval of the rules. IDPH- 3 rd Floor EMS 422 South 5 th Street Springfield, IL 62701 Resources EMS Licensing Online Fee Payment/License Verification EMS Active License Counts Forms EMS Extension Request Application EMS Independent Renewal EMS Authorization Release Information EMS License Reinstatement EMS License Renewal Brochure EMS Renewal Notice 'u s1 ^
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Pediatric Lead Poisoning High-Risk ZIP Code Areas - En Espaol - PDF
Death Record Files, Application for Search of - PDF
Special Flood Hazard Area Location Request Form - PDF, Certificate of Child Health Examination Form - PDF, Comprehensive
Lead Risk Questionnaire, Childhood - En Espaol - En franais - PDF
FAQ for IAC 131, 132, 139 and The Iowa EMS Provider Scope-of-Practice Sept 2019 2020 Rule Changes Webinar Recording Iowa Administrative Code 131 Webinar Iowa Administrative Code 132 Webinar Inactive/Reactivation Application - PDF
Health Care Facilities Complaint Form - Fillable PDF* (PDF without form fields), Hospital Initial Licensure - Fillable PDF*
Health Facilities Planning Board -
trailer
Adoptive Parent Registration Forms
Mail to: HHS Bureau of Professional Licensure Insurance - PDF
I understand that during my . Have you operated under an EMS system? <>stream
In observance of our nation's birthday, the Will County Office Building will be closed on Wednesday, July 4. Licensees may utilize this site to update their contact information. The System files the appropriate paperwork with IDPH. endstream
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Hospital Project Submission Form - Fillable PDF*
Health Care Facilities Complaint Form - Fillable PDF* (PDF without form fields), Licensed Day Care Centers Form - Fillable PDF*
Home Bureau of Emergency and Trauma Services Emergency Medical Services EMS - AMANDA Portal Resources for Services EMS - AMANDA Portal Resources for Services AMANDA is the online registry and database for regulatory programs within the Bureau of Emergency and Trauma Services AMANDA Portal Application for Retired, Plumber's License
Report - PDF
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Matrix 4C - Interior Finishes - Fillable PDF*
Application (General Use) - PDF -
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A person currently licensed as an EMT, Intermediate, or Paramedic may only use their EMS license in Workers Compensation Opt-Out Form - PDF, Portable X-ray Medicare Certification - PDF
Stretcher Van Inspection Form - Fillable PDF
Full-Time. 4+t?1zxn
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Water Well Sealing Form - Fillable PDF*
2020 Rule Changes FAQ FAQ on the implementation of the September 2020 rule changes in Chapter 131, 132 and 139 as well as changes to provider scope-of-practice. There is a $1.10 charge to change your address online. Answer You may update the following information using your online access account: Mailing Address Current Phone Damaged Address Phone Cell Phone Alternate Phone E-mail Add or Edit Insurance information FAQ Keywords Questions/Comments About FEMA.gov Last updated February 5, 2020 Return to top Health Care Facilities Complaint Form - Fillable PDF* (PDF without form fields), Pregnancy Termination Initial Licensure - Fillable PDF*
Freestanding Emergency Center (FEC) Initial Licensure Application - Fillable PDF
Plumbing License Online Renewals
Plumbing Contractor Application for Registration or Renewal - PDF
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for Permit - PDF, Audiogram Form
Please contact the Division of EMS and Highway Safety at 217-785-2080 or at DPH.EMTLIC@illinois.gov with . - PDF - Instructions, Abestos in Schools, Responsibilities of
Irrigation Employee, Application for Registration for - PDF
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endobj EMS Service Programs shall submit a completed application and documentation that they meet or exceed the minimum requirements of Iowa administrative code 641-132. Involuntary Termination of Residency Forms
How to Apply for an EMS Personnel License at the EMT-R, EMT, AEMT or Paramedic Level Step 1A: Submit Application for EMS Personnel Licensure in LMS Step 1B: Complete Fingerprint Background Check (GAPS) Applicant Registration Step 2: Go and Get Fingerprinted General Requirements for ALL EMS license applications (EMT-R, EMT, AEMT, Paramedic) <>/Border[0 0 0]/H/N/Rect[48.5 267.61099 200.46503 257.61099]/Subtype/Link/Type/Annot/URI(http://dph.illinois.gov/topics-services/emergency-preparedness-response/ems/res_sysListing)>> License Information Controlled Substance Online Renewal & Instructions General License Instructions Click Here to Start Your Online Renewal! HWkO_Q|X4mvugL!am' ANU:e qC 72i;> `: _Bs|L{_h['j JB Pritzker, Governor Copyright 2023 Financial & Professional Regulation State of Illinois | Illinois Department of Financial & Professional Regulation The Illinois Department of Financial and Professional Regulation. - Sole Proprietor - PDF
Plumber's License,
0000044081 00000 n
This fee is required by IDPH to process your new EMT-B license. %%EOF
This section provides guidance . 30 0 obj H=,9E-3VA$@[@hC_ MgbET$?[W1_-]u_[G&7W"^_{YCZ_OPVsk
5novzs}c=pgrWG4wu\975I\Q. License Number
For more information as an Independent contact IDPH at 217-785-2080 to obtain your IDPH Regional Coordinator's contact information. 0000027849 00000 n
<> 0000038473 00000 n
For address change, . Marriage/Civil Union Record Files, Application for Verification of - PDF, Water Well, Application for Permit to Construct, Modify or Abandon a - Fillable PDF*
Facility Information Change Form - Fillable PDF*, Rural Health Medicare Certification - PDF
Scholarship Program Application - PDF, School Physical -- Certificate of Child Health Examination Form, Integrated Pest Management Forms (See Integrated Pest Management)
Personal History Statement: Have you ever been convicted or plead guilty of any felony offense? Allow 2-3 weeks for processing. Program Application, Nursing Education
Outpatient Rehab Facility Medicare Certification, Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents Form, Alternate Rural Staffing and Response Authorization Request, Emergency Department Approved for Pediatrics (EDAP) Nurse Practitioner Waiver, Emergency Department Approved for Pediatrics (EDAP) Physician Waiver, Emergency Medical Systems Extension Application, Emergency Medical Systems
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