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Forms
Last updated 7.21.2010
Below is a list of forms provided by REMO and other local, state, and national institutions.
Continuing Medical Education (CME)
2010 Provider Turn-Around Document
Agency has the option of using remo-als.com electronic system or all paper submission.
2010 Turnaround Document Instructions
Paper Turnaround Document (Excel; .xls)
Paper Turnaround Document (PDF)
REMO Regional CME Application Form PDF (49KB)
CME Certificate PDF (102KB)
CME Attendance Roster PDF (33KB)
CME Participation Survey PDF (311KB)
Application for Outside REMO CME Credit PDF (123KB)
Public Access Defibrillation (PAD)
NYSDOH Form 4135 Notice of Intent to provide Public Access Defibrillation
Acrobat PDF (84KB)
NYSDOH Policy Statement 07-04- Public Access Defibrillation
PDF (139KB)
NYSDOH Section 3000-a NY Public Health Law PDF (350KB)
NYSDOH Section 3000-b NY Public Health Law p1 PDF (305KB)
REMO Collaborative Agreement AED Word doc (27KB)
REMO PAD Checklist PDF (120KB)
REMO PAD Provider Packet Table of Contents Word doc (88KB)
REMO PAD QI Report Acrobat PDF (238KB)
REMO Quarterly PAD Report Word Doc (43KB)
REMO Regional Council Collaborative Agreement for PAD Word Doc (27KB)
REMO Roles and Responsibilities for PAD providers Acrobat PDF (120KB)
BLS Treatment Modalities
NYSDOH Aspirin Administration 2007-01 PDF (80KB)
NYDOH Form 4188 Notice of Intent to Possess and Use Epinephrine Auto Injector
and Epinephrine Auto-Injector Collaborative Agreement
PDF (1.7MB)
REMO BLS Albuterol Administration Program Word Doc (184KB)
REMO BLS Albuterol QI Form Word doc (56KB)
REMO Epi-Pen QI Form Word doc (29KB)
BLS Glucometer - application package Adobe PDF (1MB)
Credentialling
Original Internship Manual/PacketPDF doc (1461KB)
REMO AEMT Statement of Agreement Word doc (30KB) PDF (14KB)
REMO ALS Provider On-Line Form Word doc (24KB)
REMO Application for Medical Control Privileges PDF (80KB)
REMO Internship Completion Checklist Word doc (40KB)
REMO Medical Director Verification Letter Word doc (23KB)
Other
NYSDOH Form 3486 Disclosure of Ownership Acrobat PDF (48KB)
NYSDOH Form 4081 Initial Limited Service Laboratory Registration
Acrobat PDF (328KB)
REMO Airway QI Audit Tool Acrobat PDF (59KB)
REMO Report of Meaningful Positive Result - SAVE Acrobat PDF (235KB)
REMO Regional Nursing Home Transfer Form Acrobat PDF (75KB)