"Emergency Medical Services (EMS) Systems License Reinstatement Application" - Illinois

Emergency Medical Services (EMS) Systems License Reinstatement Application is a legal document that was released by the Illinois Department of Public Health - a government authority operating within Illinois.

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Emergency Medical Services (EMS) Systems
License Reinstatement Application
Instruction for Completing the License Reinstatement Request
Notice: All applicants must go through an EMS System.
Purpose: This form shall be completed by an emergency medical technician-basic (EMT-B), emergency medical technician-intermediate
(EMT-I), advanced emergency medical technician (A-EMT), or Paramedic whose license has been expired for fewer than 36 consecutive
months and who is requesting reinstatement.
Attach the following items to the completed application:
• Letter requesting reinstatement
• Documentation of required continuing education hours (legible copies only)
• Copy of the applicant’s current Healthcare Provider Basic Life Support (BLS) card
• For applicants convicted of a felony, the following steps need to be completed:
Contact IDPH, Division of EMS and Highway Safety at 217-785-2080 to obtain a Uniform Conviction Information Act Fingerprint
Request Form, along with an Emergency Medical Services (EMS) Authorization for Release of Information form.
Submit the completed Uniform Conviction Information Act Fingerprint Request form and a $20.00 processing fee directly to the
Illinois State Police.
Submit the completed Emergency Medical Services (EMS) Authorization for Release of Information form along with a statement
regarding the conviction and any references of good character from former employers, EMS instructors, or persons of authority,
directly to IDPH
Submit the completed application and other required documentation to the EMS System authorizing the reinstatement.
Upon review and authorization of the application and documentation by the EMS System, the System shall submit the application, all
required documentation and fee to IDPH for determination of eligibility of reinstatement. The applicant and EMS System will be notified
of the determination accordingly.
If you have any questions, contact the Illinois Department of Public Health, Division of Emergency Medical Services and Highway Safety,
at 217-785-2080.
Submit to:
Illinois Department of Public Health
Division of EMS and Highway Safety
Attention: Reinstatement Review
422 South Fifth Street, Third Floor
Springfield, Illinois 62701
IOCI 16-580
Emergency Medical Services (EMS) Systems
License Reinstatement Application
Instruction for Completing the License Reinstatement Request
Notice: All applicants must go through an EMS System.
Purpose: This form shall be completed by an emergency medical technician-basic (EMT-B), emergency medical technician-intermediate
(EMT-I), advanced emergency medical technician (A-EMT), or Paramedic whose license has been expired for fewer than 36 consecutive
months and who is requesting reinstatement.
Attach the following items to the completed application:
• Letter requesting reinstatement
• Documentation of required continuing education hours (legible copies only)
• Copy of the applicant’s current Healthcare Provider Basic Life Support (BLS) card
• For applicants convicted of a felony, the following steps need to be completed:
Contact IDPH, Division of EMS and Highway Safety at 217-785-2080 to obtain a Uniform Conviction Information Act Fingerprint
Request Form, along with an Emergency Medical Services (EMS) Authorization for Release of Information form.
Submit the completed Uniform Conviction Information Act Fingerprint Request form and a $20.00 processing fee directly to the
Illinois State Police.
Submit the completed Emergency Medical Services (EMS) Authorization for Release of Information form along with a statement
regarding the conviction and any references of good character from former employers, EMS instructors, or persons of authority,
directly to IDPH
Submit the completed application and other required documentation to the EMS System authorizing the reinstatement.
Upon review and authorization of the application and documentation by the EMS System, the System shall submit the application, all
required documentation and fee to IDPH for determination of eligibility of reinstatement. The applicant and EMS System will be notified
of the determination accordingly.
If you have any questions, contact the Illinois Department of Public Health, Division of Emergency Medical Services and Highway Safety,
at 217-785-2080.
Submit to:
Illinois Department of Public Health
Division of EMS and Highway Safety
Attention: Reinstatement Review
422 South Fifth Street, Third Floor
Springfield, Illinois 62701
IOCI 16-580
Emergency Medical Services (EMS) Systems
License Reinstatement Application
All areas must be completed or the application will be returned unapproved.
Applicant Name
Address
Apt. Number
City
State
ZIP Code
Phone Number
E-mail Address
Social Security Number
Date of Birth
Level of License to be Reinstated:
EMT-B
A-EMT/EMT I
Paramedic
License Number to be Reinstated
Expiration Date of License to be Reinstated
Personal History Statement:
Have you ever been convicted or plead guilty of any felony offense?
Yes
No
If yes, provide an explanation, in your own words, of the nature of the offense. An additional fee and authorization for release of
information must be submitted to IDPH to obtain a criminal history report from the Illinois State Police or other law enforcement
agency. The release form and fee schedule can be found at
http://dph.illinois.gov/topics-services/emergency-preparedness-response/
ems/licensing.
Child Support Statement:
Are you more than 30 days delinquent in complying with a child support order?
Yes
No
Under penalty of perjury, I declare that I have reviewed the application and all supporting documents submitted by me in connection
with this request and, to the best of my knowledge, they are correct and complete.
Signature of Applicant
Date
I attest that the above named applicant has completed all didactic, clinical and skill competencies required by this EMS system program.
I recommend this applicant be allowed to attempt to successfully complete the testing exam for licensure reinstatement at the level
indicated.
EMS Medical Director Signature
Date
System Number
Reviewed and approved by
EMS System Coordinator Signature
Date
Reviewed and processed by
Education and Testing Coordinator
Date
IOCI 16-580
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