PAD Provider Packet

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Recredentialing for Providers

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NYS Epinephrine Auto-Injector Notice of Intent

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ALS Medical Control Record

This form is to be completed by providers when they contact medical control.

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CPAP QI Form

This form is to be completed by the EMT/AEMT who has applied CPAP to a patient using the REMO CPAP protocol. This form should be returned, along with a copy of the completed PCR. These should be returned with the yellow copies of the PCR's by the 15th of the next month.

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CME Attendance

To be used for all attendees at a recognized CME 

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CME Certificate

This certificate should be issued by a CIC at an approved CME. By using the “Sign” function of Adobe Reader a CIC can add text to the appropriate fields.

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BLS Glucometry

James Holland

Health Program Administrator, Clinical Laboratory Evaluation Program

Wadsworth Center, New York State Department of Health

Phone: (518) 402-4141| James.Holland@health.ny.gov

Fax: (518) 449-6902

www.wadsworth.org

http://www.wadsworth.org/regulatory/clep/limited-service-lab-certs

REMO Credentialing Process

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PAD Usage QI Report

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REMO Collaborative Agreement

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REMO RMA Form

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PAD Quarterly Report

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Roles and Responsibilities for PAD Providers

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Epi-QI Form

​This form is to be completed and sent to REMO within 2 business days of the use of an Epinephrine auto-injector.

 

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NYS Public Health Law Section 3000a-b

http://www.health.ny.gov/nysdoh/ems/art30.htm#BM3000b

​The information contained on this website is not the official version of the New York State Public Health Law. No representation is made as to its accuracy. To ensure accuracy and for evidentiary purposes, reference should be made to the official version available on the New York State Legislature Web site. Click on the link for "Laws of New York" and then the link for "PBH Public Health".

The information contains legal definitions used in collaborative agreements.

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NYS Policy Statement 09-03 Re: PAD

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NYS PAD Notice of Intent

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BLS Naloxone QI Form

This form is to be completed by the EMT/AEMT who has administered Naloxone to a patient using the BLS Naloxone protocol. This form should be returned, along with a copy of the completed PCR, to the appropriate Program Agency within 24 hours of administration in order to restock the BLS Naloxone Kit.

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BLS Albuterol QI Form

​This form is to be completed by the EMT/AEMT-I who has administered Albuterol to a patient using the REMO Albuterol protocol. This form should be returned, along with a copy of the completed PCR. These should be returned with the yellow copies of the PCRs by the 15th of the next month

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PAD Checklist

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Report of Meaningful Positive Result

This form is to be used for all REMO providers whose skills and efforts at an EMS event are deserving of recognition.

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REMO ePCR Policy Agreement

​As the electronic age advances REMO will continue to advance as well. In order to assist the regional agencies in meeting the demands of collecting electronic patient care data, the following policy has been

developed. In order to participate in an electronic PCR program agencies must complete this form.

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CME Participant Survey

​CICs can use this form as a program evaluation tool.

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