bls service medical director agreement - Eastern EMS Council

BLS SERVICE MEDICAL DIRECTOR AGREEMENT
I, the undersigned physician, represent that I satisfy the criteria to serve as a BLS
medical director, and agree to perform the duties of a BLS service medical
director for the following BLS ambulance service/Quick Response Service:
NAME
(Ambulance Service)
(Address)
(City) (State) (Zip)
AFFILIATE #
Qualifications:
I am approved as a service medical director in
(Region)
or meet the following:
1. I hold a valid PA license to practice in the Commonwealth as a Doctor of
Medicine or Doctor of Osteopathy, i.e. Medicine.
2. I am board certified in emergency medicine or have successfully completed
an ACLS training program.
It is recommended by the Eastern PA EMS Council that I:
1. Have experience in base station radio direction of pre-hospital personnel and
the operation of emergency dispatch.
2. Have knowledge of the capabilities and limitations of ambulances, including
air ambulance and pre-hospital personnel.

3. Have knowledge of potential medical complications that may arise during
transport of a patient by an ambulance service.
In accepting the responsibility of a BLS service medical director for the above
referenced service, I acknowledge that my duties and responsibilities will include:
1. insuring AED training requirements (when applicable) are met.
2. authorize AED providers (when applicable) and maintain a current listing.
3. providing medical guidance and advice to the BLS ambulance service.
4. evaluating the quality of patient care provided by the pre-hospital personnel
utilized by the BLS ambulance service, including performing medical audits of
patient care provided by the pre-hospital personnel.
I agree that I will provide the BLS ambulance service with 30 days notice prior to
terminating this agreement, and it must be renewed upon relicensure of the
service.
Signature of Physician
Printed Name of Physician
Medical License Number
Expiration Date
Chief Officer of Service
Date