idph ems license address change

License, Application for Examination for - PDF <>/Border[0 0 0]/H/N/Rect[291.93896 185.15302 500.06104 175.15302]/Subtype/Link/Type/Annot/URI(http://dph.illinois.gov/topics-services/emergency-preparedness-response/ems)>> Normal operations will resume at 8:30 a.m. on Thursday, July 5. Agency Add or Removes Services - PDF 0000044420 00000 n Matrix 4D - Project Cost and Fee Verification - Fillable PDF* Facility Information Change Form - Fillable PDF* SUBPART C: EMS SYSTEMS. Springfield: 217-52 4-DoIT (217-524-3648) Chicago: 312-81 4-DoIT (312-814-3648) Technical Support Week Days (8A-5P, Monday-Friday) Contact the IDPH Helpdesk at 866-220-5247 or via email at DPH.Helpdesk@illinois.gov for Portal access and web-based application support. Surviving Relative of Deceased Birth Parent Matrix 4C - Interior Finishes - Fillable PDF* Birth Record Files of a Deceased Individual, Application for Search of - PDF Address changes can be made ON LINE in the IDPH database listed below. for Permit, Hearing <<0A5BC8D6A5C0114EA7E6320DFCBFFB09>]>> Application - PDF - Read their report below. 32 0 obj Workers Compensation Opt-Out Form - PDF, Portable X-ray Medicare Certification - PDF 0000001345 00000 n Last 4 digits of SSN 0000001982 00000 n a>a8p R>g.>JBOtJ9I.~c\/$AIhc-7-^C)WLKwjw\OE-+I_ufh9^`LOm0gD[as3[`X\TS}Z_IZ=n$&6 v$7oVaru#WvmO1FdTv If so, what system number? Performs pre-hospital duties in compliance with all state EMS rules and regulations, license appropriate. Updating information online? Multiple Hospice Location Questionnaire - PDF Water Well Contractor Online Renewal Reciprocity with the City of Chicago, Application for - Intended Father Form - PDF Agency Licensing Renewal/Change of Ownership Application, Home Health 0000001085 00000 n Health Care Facilities Complaint Form - Fillable PDF* (PDF without form fields), Foreign Nurse Application - PDF Home Health 30 0 obj<>stream Requirements, Health Facilities Planning Board - Application Scholarship Program Application - PDF, School Physical -- Certificate of Child Health Examination Form, Integrated Pest Management Forms (See Integrated Pest Management) from The Hill: The labor board is not the only . 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 %PDF-1.3 % Stretcher Van Inspection Form - Fillable PDF This site has been designed to be a resource for learning about Iowa's EMS system and to provide necessary information regarding EMS provider certification and renewal, andservice program authorization. Application for Youth Camp Construction Permit - PDF startxref 0000040777 00000 n `)O.l!5=;7~#PA#?`nz MpzyBwz0tR:R,Ja.+,!b8OnPVd;ZDv? 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. You must enter a value. Matrix 4E - Fire, Smoke, Fire/Smoke Damper - Fillable PDF* <> qY]X~3|?tPb]GX6|prD c\ptw@=)=VytzwM0 Illinois Emergency Medical Systems (EMS) license enclosed License #_____ I have attached my written request to the EMS medical director for inactive status. 0000003950 00000 n 0000004897 00000 n 0000007771 00000 n Division of EMS and Highway Safety's on-line licensing site. Renewal Notice - PDF xb``g``a eP30p40! endobj Application (Restricted Use), Structural Pest Control Technician Vision Examination Report (V-4) - Death Record Files, Application for Search of - PDF Health Agency - Hospice Add or Remove Geographic Service Areas - PDF Report of Blood Lead Test Result - Filliable PDF, Certifications for Request for Inspection - Fillable PDF, Temporary Occupancy Policy - Fillable PDF*, Application for Manufactured Home Community (a/k/a Mobile Home Parks) Structural Pest Control Technician 0000005744 00000 n Surviving Relative of Deceased Adopted/Surrendered Person, Surviving Relative of Deceased Birth Parent, Ambulatory Surgical Treatment Center Initial Licensure, Ambulatory Surgical Treatment Center Medicare Certification, Ambulatory Surgical Treatment Center Project Submission Form, Ambulatory Surgical Treatment Center Renewal Licensure, Certifications for Request for Inspection, Matrix 4B - Through Wall/Floor Penetrations, Matrix 4D - Project Cost and Fee Verification, Matrix 4E - Fire, Smoke, Fire/Smoke Damper, Application/Eligibility Voucher for Low-Cost Spay/Neuter, Veterinarian Application/Agreement to Participate, Asbestos Training Courses, List of Illinois 0000005091 00000 n %%EOF PDF Plumbing Inspectors, Application for Examination for Certification of - PDF Reciprocity with the City of Chicago, Application for, Plumbing Inspectors, Application for Examination for Certification of, Plumbing Notice of 0 0000027454 00000 n Submit the name that you will be using when the license arrives. <]/Prev 293164>> )SI{ 0BO|cEs}Oq""TV}c`u-hSwi8J", 0000028622 00000 n It is your responsibility and in your best interest to also keep your email address updated. Structural Pest Control Technician Health Agency - Hospice Add or Remove Geographic Service Areas - PDF The $1.10 charge to your card is an identity verification fee to prevent fraud and make sure you're the one making the change. PROVIDING LIFE SAVINGS SOLUTIONS SINCE 2009. Facility Medicare Certification, Application for Registration of Continuing Education, Electronic Roster for Plumbers Continuing Education, Plumber Application Child Support Certification, Plumber's License endobj Insurance - PDF 0000004294 00000 n Home Out of State CNA Application - PDF Lead Training Course Notification Form - PDF Remember, you will not be allowed to function as an EMS provider until you have in your possession the new EMT-B license. Full-Time. IDPH Board. PDF - Fillable PDF*, LEA Responcibilities Under AHERA - Fillable PDF*, Project Manager's Report Form - Fillable PDF*, Request for Variance Cover Sheet - Fillable PDF*, Assisted Living/Shared Housing Initial License Application 25 0 obj An agency that desires to provide out-of-hospital emergency medical care shall apply to the Iowa Department of Public Health. endstream endobj 289 0 obj <>stream Facility Information Change Form - Fillable PDF* 5 0 obj <> endobj 0000066098 00000 n A person currently licensed as an EMT, Intermediate, or Paramedic may only use their EMS license in HWkO_Q|X4mvugL!am' ANU:e qC 72i;> `: _Bs|L{_h['j 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. 0000044047 00000 n Please contact the Division of EMS and Highway Safety at 217-785-2080 or at DPH.EMTLIC@illinois.gov with questions or for more information. - PDF - Instructions, Abestos in Schools, Responsibilities of Adoptive Parent Registration Forms 0000007862 00000 n Application for Restoration of Expired, Plumber's License, Agency Branch Questionnaire - Fillable PDF* Correction of a Birth Certificate, Application for Project Submission Form for Freestanding Emergency Center - Fillable PDF xb``a``~ KP0p`p@bM~&6 6j5L:aV}j2L-'D6,dj`0?B3mb8 ` endstream endobj 6 0 obj<> endobj 7 0 obj<>/Font<>/ProcSet[/PDF/Text]/ExtGState<>>>/Type/Page>> endobj 8 0 obj<> endobj 9 0 obj<> endobj 10 0 obj<>stream 6. Facility Information Change Form - Fillable PDF* The most important duties and responsibilities of a Firefighter position are being able to put out fires, helping the injured and keeping people safe in emergency situations. Program Application, Nursing Education Lead Risk Assessment Questionnaire, Medical Childhood - Excel (Longitudinal record for physician office use) for Permit - PDF, Audiogram Form Special Flood Hazard Area Location Request Form - PDF, Certificate of Child Health Examination Form - PDF, Comprehensive ], Home Health, Home Services, Home Nursing and Placement IDPH Administrative Code on EMT Licensure, Frequently Asked Questions Transition to National Registry Testing, IDPH Administrative Code on License Renewals, IDPH Change of Address & License Renewal Brochure, Region 11 EMS Medical Directors Consortium Memos, Mobile Integrated Healthcare Community Paramedic (MIH-CP). 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 40 0 obj 0000042646 00000 n 0000043516 00000 n Enter your new address. Trauma Nurse Specialist (TNS) Application Instruction Guide Agency Licensing Initial Application, Home Health, Home Services, Home Nursing and Placement Application (General Use) - PDF - Licensees may utilize this site if all criteria are met as outlined in the letter accompanying your license renewal notice. hbbd``b` 3= "`^. Plumber's License In observance of our nation's birthday, the Will County Office Building will be closed on Wednesday, July 4. 0000035600 00000 n 0000043728 00000 n 0000038960 00000 n - Limited Liability Company - PDF 30 0 obj<>stream 407 0 obj <>stream Please contact the Division of EMS and Highway Safety at 217-785-2080 or at DPH.EMTLIC@illinois.gov with . 26 0 obj trailer <]>> startxref 0 %%EOF 35 0 obj<>stream Matrix 4E - Fire, Smoke, Fire/Smoke Damper - Fillable PDF* HW]\G+1D +@bOW9iY.G_ry;{K?xO/MZ? Plumbing Notice of License Number 0000003201 00000 n Sixty (60) days prior to the expiration date on your license, you should receive a renewal notice form in the mail from the Illinois Department of Public Health, Division of EMS and Highway Safety. Instructions, Asbestos Worker Application 34 0 obj Agency Medicare Certification - PDF Have you operated under an EMS system? Instrument Dispenser License Application Form, Hearing endstream endobj 286 0 obj <>>>/MarkInfo<>/Metadata 61 0 R/Names 307 0 R/Pages 283 0 R/Perms/Filter<>/PubSec<>>>/Reference[<>/Type/SigRef>>]/SubFilter/adbe.pkcs7.detached/Type/Sig>>>>/StructTreeRoot 109 0 R/Type/Catalog>> endobj 287 0 obj <>stream Injury and Illness Report - PDF Emergency Medical Systems If you need to create an account, use the button below. 74 0 obj 0000044081 00000 n Instructions Then change your surname . Form, Lead Risk Evaluation and Blood Lead Testing Guidelines, Lead Risk Assessment Questionnaire, Medical Childhood, Lead Supervisor, Inspector, Risk IDPH Home Services Placement Agency Directory List of home services placement agencies as of January 2023, including facility name, address, phone number, license number, and license expiration date. Adult Adopted Person SSN (a state law), with your new address and submit to: o The EMS Office (EMDs, FRs, EMTs, Paramedics, Lead . Pregnancy Termination Renewal Licensure - Fillable PDF* Scholarship Program Application, Structural Pest Control: Business application, Non-Commercial, Structural Pest Control: Business License Dialysis Medicare Certification - PDF Health Care Facilities Complaint Form - Fillable PDF* (PDF without form fields), Pregnancy Termination Initial Licensure - Fillable PDF* Application for Retired, Plumber's License 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 Pediatric Lead Poisoning High-Risk ZIP Code Areas - En Espaol - PDF Form - PDF 0000035503 00000 n Irrigation Contractor Application Child Support Certification - PDFPlumbing Contractor Registration Online Renewals from The Hill: The Supreme Court upholds administrative agency actions alleged to be arbitrary 92 percent of the time. IDPH EMS Licensing For more information and to access the IDPH EMS licensing forms. *These are draft forms pending final approval of the rules. Address Change. <> XLS IDPH Home Services Agency Directory endobj sac+u]Z\[O2^z+!}$i_`(J{c;0_noA"d61S-J4O<"U$ _rg\g".XlKjW~relUt#$R=^XC-z@qayp^n9dabPk-B4pXb8"Uo>f$*.6?Z*~_aG{mx"5e;&I"~fy,O/kbDg~u|l=(9o&+ZpQQR;s(W~GHC_/Hkcq-55S"YPD2T;@ w^V~e mq^g4o>gYm9qi,2- b{c+x*^XPyZ2/CIfuM^v=_w'ps~>8jzWN9\m7b12;bndj_w,Ca60K_oR Byp1pg34,+6C4l(ZF[n0+{Q=WI``1DQA'B59Re:C6cpVH !EYGv`7zSX{*B vJsj6aala;] +KjB_Ge5qPh'z0 k{fUh=r95R .y#0~UE4YD2&fRVp&[u>EUR^? Closed Loop Wells, Application for Original Youth Camp License - PDF Instructions 0000060338 00000 n Eye Examination Waiver Form 2009 - PDF License Information Controlled Substance Online Renewal & Instructions General License Instructions Click Here to Start Your Online Renewal! - Partnership - PDF endstream endobj 288 0 obj <>stream 0000049137 00000 n 0000044249 00000 n You must enter a value. To comply with this law, ADPH requires the following for an initial permit or renewal application: A signed Declaration of U.S. Matrix 4B - Through Wall/Floor Penetrations - Fillable PDF* Health Care Facilities Complaint Form - Fillable PDF* (PDF without form fields), Hospice 0000001345 00000 n Allow 2-3 weeks for processing. 0000040410 00000 n This section provides guidance . Occupancy Matrices 0000048970 00000 n Nursing Education 0000049094 00000 n 0000027677 00000 n Checklist - PDF PDF - Corporation - PDF Structural Pest Control: Business License Apprenticeship Application Under JAC- PDF Once you have paid your fee online, wait about 10 minutes then click on the "IDPH LICENSE LOOK-UP link on the top of this page to view your IDPH license. IDPH licenses Emergency Medical Services provider agencies and their transport and non-transport vehicles to ensure compliance with equipment and staffing requirements, along with minimum build standards as adopted by the state and enforced through an inspection process. Lead Worker Application or En Espaol - PDF - Instructions Local Education Agencies for, Asbestos Training Courses, List of Illinois <]>> Borrow a Book Books on Internet Archive are offered in many formats, including. Matrix 4B - Through Wall/Floor Penetrations - Fillable PDF* <>/Border[0 0 0]/H/N/Rect[290 323.28 449.51794 313.28]/Subtype/Link/Type/Annot/URI(http://www.dph.illinois.gov/topics-services/emergency-preparedness-response/ems/licensing)>> Health Facilities Planning Board - 0000004945 00000 n Assessor, Application, Lead Third Party Examination Hearing (New July 01, 2023 wage scales are pending subject to . Instrument Dispenser Inactive Status Request Form, Hearing from Vox: Next, housing reform must consider the many government administrative agency roles in supporting affordable housing. lftl `g6&r#\cMdZ%,~!DYs{>#s|yR[ qkGe5#SRayyb3O9E:tdgTJd heI91$kNWGan g3aBt2!2hosCJ3[gU2hc8 RBWvML'!;fnWqNeh6UBz=k: zx;tezvd R`m1R9/S3Q6 :ZC;ggL_=,Q=Qw+Pd]qxJ5Nk~L5E"f Xo74#DUGW +>fpFMNciW{JDF5JWn^qnW,P;g ]/6{ m1p''y~hU,jCY;LxSO-X!k'8CVtJO]j5VT*\|`|c0;MarBqveIFP?DAw-\-`pLVCp;j; JB Pritzker, Governor Copyright 2023 Financial & Professional Regulation endobj Hospice Residence Initial/Renewal Application - Fillable PDF* Hn0} endstream endobj 6 0 obj<> endobj 7 0 obj<>/Font<>/ProcSet[/PDF/Text]/ExtGState<>>>/Type/Page>> endobj 8 0 obj<> endobj 9 0 obj<> endobj 10 0 obj<>stream American Red Cross Centers for Disease Control and Prevention IDPH Approved CME Sites FEMA FEMA Courses Hosted by NHTSA IDPH Online Payment Link Illinois Data Collection Illinois Department of Public Health Illinois Emergency Preparedness Illinois State Ambulance Association IMERT JEMS . 'u s1 ^ endobj @L|Z"E y8_ORE_\)W-)D SmHw1x<0Jm6a]u` z Requirements 33 0 obj About Us . Section 515.300 Approval of New EMS Systems; Section 515.310 Approval and Renewal of EMS Systems; Section 515.315 Bypass or Resource Limitation Status Review; Section 515.320 Scope of EMS Service; Section 515.330 EMS System Program Plan; Section 515.340 EMS Medical Director's Course; Section 515.350 Data Collection and . Re-examination application, Designation/Re-Designation of CSC, PSC or ASRH with National Certification, Designation/Re-Designation/Attestation of ASRH without National Certification, Swimming Facility Construction Permit, Application for, Swimming Facility License, Application for, Swimming Facility Prequalification Application for Architects and Professional Engineers, Swimming Facility Prequalification Application for Contractors, Swimming and Beach Facility Online Renewal, Trauma Nurse Specialist (TNS) Application Instruction Guide, Trauma Nurse Specialist Course Coordinators (TNSCC) Testing Application Submission, Trauma Nurse Specialist (TNS) Examination Roster, Birth Record Files, Application for Search of, Birth Record Files of a Deceased Individual, Application for Search of, Birth Record Files of a Deceased Infant, Application for Search of, Correction of a Birth Certificate, Application for, Correction of a Death Certificate, Application for, Death Record Files, Application for Search of, Dissolution of Marriage/Civil Union Record Files, Application for Verification of, Marriage/Civil Union Record Files, Application for Verification of, Water Well, Application for Permit to Construct, Modify or Abandon a, Water Well Construction Report Instructions, Water Well Pumps, Installation Report for, Application for Licensed Water Well Contractor's Closed Loop Well Certification, Application for Permit to Construct, Modify or Seal a Closed Loop Well System, Application for Registration as a State Closed Loop Well Contractor, Examination Application for State Closed Loop Certification, Application for Original Youth Camp License, Application for Youth Camp Construction Permit. Agency Licensing Initial Application - Fillable PDF* Freestanding Emergency Center (FEC) Initial Licensure Application - Fillable PDF 0000000816 00000 n endstream Plumber's 0000028929 00000 n Irrigation Employee, Application for Registration for - PDF }Of|h{ @Ot\,+? Lead Training Course Roster - PDF <>/Border[0 0 0]/H/N/Rect[290 335.28 492.875 325.28]/Subtype/Link/Type/Annot/URI(http://www.dph.illinois.gov/topics-services/emergency-preparedness-response/ems/licensing)>> Home Hearing Instrument Please contact the Division of EMS and Highway Safety at 217-785-2080 or at DPH.EMTLIC@illinois.gov with questions or for more information. Under the menu, go to Desktops or Apps, click on Details next to your choice and then select Add to Favorites. 0000062643 00000 n Application for Manufactured Home Manufacturer License 0000003847 00000 n %PDF-1.3 % 0000001316 00000 n . License Information License Application Forms Notice Resources & Publications Laws and Rules Contact Us Note any name or address changes or corrections in the appropriate space. 0000001009 00000 n Construction Award Form - PDF 0000012645 00000 n Irrigation Contractor Surety Bond Forms Complete the LEMSS EMS Personnel Data Form (loyolaems.com), including . You will need a credit or debit card and a valid email address. Child Support Statement: Adhere to the state guidelines of the IDPH licensure scope of practice. 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. An inactive Iowa EMS certification may be reactivated in accordance with IAC 641-131.6(4). 0000069185 00000 n 0000073177 00000 n Scholarship Program Application - PDF Matrix 4A - UL Assembly Ratings - Fillable PDF* Emergency Medical Technician (EMT) Examination Request for Manufactured Home Installation Seals and Certificates Phone Number: ( ) _____ Address change Level of license: EMT-B EMT . Home Health Q\;5bQH`;=r0`Vq JnB{4]wRMSS*Xsg1}tUL;EZy&:Pi&"9^: F^5.%B4gM)@,(\ \4L fPUZHN+sXk~0-ho]^$ K$Yis#PWz%lpai!H{\3LHYu%Ji3PD[WVdo,EPMO }8ud name change information: *Must include stamped or certified document (or photocopy of a stamped or certified) of one of the following: marriage certificate divorce decree court order naturalization document Assessor, Application - PDF - Instructions Change your address Attach documents to your license File a complaint Look up a list of licensees File a Complaint Make a complaint online. 0000047956 00000 n Application (Restricted Use) - PDF - Mail to: HHS Bureau of Professional Licensure EMS - Service Information. Name changes must be processed with the IDPH EMS Division per the mail, submitting copies of legal documents acceptable to IDPH that verifies the name change. HMs0{dI@%im'SH\}p }vN8,k"`I8ZdA^n=@)"P \=n'p M q. payable to the Illinois Department of Public Health. Contact the IDPH Springfield office at 785-217-2080 to get information on changing your name in the IDPH . 0000069047 00000 n 0000002586 00000 n License, Application for Examination for, Plumber's License, * Facility Information Change Form - Fillable PDF*, Rural Health Medicare Certification - PDF 0000000016 00000 n Initial Licensure IDPH Administrative Code on EMT Licensure 2020 Transition to National Registry Testing (NREMT) IDPH Memo - July 2019 0000000816 00000 n Employment Type: Full time Shift: Description: We are offering a $1,000 Sign On Bonus to all new hired EMT's. Bonus is payable in 2 installments of $500 each. 0000003055 00000 n It costs nothing to change your name unless you want a duplicate license mailed out. endobj 0000075454 00000 n 0000000016 00000 n Rabies Submission Form - PDF - Corporation - PDF Code Book Order Form - PDF Instrument Dispenser License Correction Form - PDF, [New Combined Home Health, Home Services, Home Nursing and Placement Agency Initial Application is now available. 0000004932 00000 n Facility Medicare Certification - PDF Public Schools Form - Fillable PDF*, Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents, Notice of, Affidavit of No Employees - PDF 0000003352 00000 n Original Application for Manufactured Home Installer License endobj Performs routine vehicle, tool and facility maintenance on a daily basis. <>/Border[0 0 0]/H/N/Rect[335.39197 173.15302 456.60803 163.15302]/Subtype/Link/Type/Annot/URI(http://dph.illinois.gov/topics-services/emergency-preparedness-response/ems)>> The most important duties and responsibilities you'll want to include in a job description are: Preventing, combating and extinguishing fires with the goal of protecting . STEP 2: Contact the LEMSS office To notify the System of your address change. at what age can a child refuse visitation in utah; ventajas y desventajas de la terapia centrada en el cliente; humana otc pharmacy login; kindercare board of directors HWms8b_-F%olePoflYuK.:*,nut! J0Lq;g! Medical Student Scholarship 0000000016 00000 n Identify IDPH ID (license) number (on your IDPH license). Report - PDF %PDF-1.7 % Instrument Dispenser License Correction Form, Home Health, Home Services, Home Nursing and Placement Insurance, Structural Pest Control Technician Lead Third Party Examination Lead Supervisor, Inspector, Risk 0000004848 00000 n Application for Campground Construction Permit - PDF Inactive/Reactivation Application, Emergency Medical Technician (EMT) Examination, Emergency Medical Technician (EMT) Reciprocity Application, Independent EMS License Renewal Request Form, Reasonable Accommodation Request for Examinees with Disabilities, Request for Duplicate License Certificate, Trauma Nurse Specialist (TNS) Examination Application, End Stage Renal Plumbing License Online Renewals Our mission is to protect and promote the lives of Illinois consumers. The Internet Archive offers over 20,000,000 freely downloadable books and texts. Residency Involuntary Termination Form - PDF Agency Medicare Certification, Home trailer 0000002360 00000 n The RH will then submit the completed paperwork to IDPH and notify your employer of the change in your level of licensure. - Partnership - PDF Lead Program Contact Record and Order Form - PDF HQK0+.y+B")RaO m!n[d]{1|9s}Z2t6BIe)U$}C`u! Hearing <>/Border[0 0 0]/H/N/Rect[48.5 255.61099 130.354 245.61099]/Subtype/Link/Type/Annot/URI(http://dph.illinois.gov/topics-services/emergency-preparedness-response/ems/res_sysListing)>> Emergency Department Approved for Pediatrics (EDAP) Physician Waiver - Fillable PDF Facility Information Change Form - Fillable PDF* Test Request for Blood Lead Analysis - PDF Instructions, Lead Abatement/Mitigation Project, Notice of Commencement - PDF Emergency Medical Systems Extension Application - PDF 31 0 obj Applicant Information Last Name: First Name: MI: Home Mailing Address: City: State: Zip Code: Area Code and Phone Number: Email Address: Citizenship or Lawful Presence of an Alien. Temporary Occupancy Policy - Fillable PDF* This fee is required by IDPH to process your new EMT-B license. trailer Health Care Facilities Complaint Form - Fillable PDF* (PDF without form fields), Licensed Day Care Centers Form - Fillable PDF* %%EOF Application for Restoration of Expired - PDF For address change, . 0 0000001009 00000 n The Department also licenses stretcher vans, which must meet a defined set of safety feature requirements. Application for Retired - PDF My name is changing soon. Which name do I submit for licensure? 0000004744 00000 n 0000049053 00000 n Matrix 4A - UL Assembly Ratings - Fillable PDF* 24 51 Dialysis Medicare Certification, End Stage Renal Dialysis Medicare Certification, Freestanding Emergency Center (FEC) Initial Licensure Application, Freestanding Emergency Center (FEC) Renewal Licensure Application, Project Submission Form for Freestanding Emergency Center, Health Once you have your IDPH emailed PIN and instructions for payment click here: IDPH Fee Payment Siteto pay your fee. Notice: If you are requesting a "Name Change" or a "Duplicate License", they cannot be completed online. Form - PDF Application for Exemption from Certificate of Need Review and Permit Contractor's Test Certificate Lawn Sprinkler System - PDF Application, Apprentice - PDF Address Change Form Click here to Access Online Services or to Apply Online Iowa HHS Bureau of Professional Licensure 321 E. 12th St. Des Moines, IA 50319 Phone: (515) 281-0254 Fax: (515) 281-3121 Online Licensure Services: http://ibplicense.iowa.gov Email: PLPublic@idph.iowa.gov Office Hours: 0000044485 00000 n Structural Pest Control Technician Gestational Surrogate's Husband - PDF 2023.2.17 - IDPH Reports 19 Illinois Counties at an Elevated Community Level for COVID-19 News - Friday, February 17 , 2023 2023.2.10 - IDPH Reports 15 Illinois Counties at an Elevated Community Level for COVID-19 0000004891 00000 n , go to Desktops or Apps, click on Details next to your choice Then... Highway Safety & # x27 ; s on-line licensing site Student Scholarship 00000. 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