Applications and Forms | Texas DSHS (2024)

Use our Online Licensing System to:

• Apply for initial EMS certification/licensure.
• Renew
• Upgrade
• Address Change
• Print certificate/license and ID.

If you need any of the following forms, click to send prepopulated email to EMS Certification.

• Texas Fingerprint Service Code
• Inactive Certification/Licensure
• Wallet Card Replacement - Include all required information.

Certification/Licensure

Link toinitial certification and licensure information.

• Name Change
  Use this form to change your name on your EMS record.
• ECA High School/GED Exemption
  Candidates must meet volunteer criteria listed in Health and Safety Code 773.058.
• Rule Exemption
  Use this form to request an exemption from EMS rules.
• Volunteer Verification
  Use this form to verify the volunteer status of an applicant.
• Surrender of EMS Certificate or License
  Use this form tosurrender your EMS Personnel certification or license, (EMS) Instructor or Coordinator certificate, (EMS) Initial Education Program, or (EMS) Continuing Education Program, or your Administrator of record (AOR) recognition.

Reciprocity

Link to reciprocity information.

• Out of State Verification Form A
  Submit the Verification Form A to each State where the applicant has ever been certified and/or is currently certified.
• Reciprocity AEMT Skills Out of State Verification Form
  Applicants seeking reciprocity at the Advanced EMT level must have training (verifiable by the certifying state agency) that includes alternative airway intubation devices, and IV initiation as required for Advanced EMT certification in Texas.

Renewal

Link to renewal information.

• Skills Verification Form for Late Renewal
  Applicants completing ALL renewal requirements between date of expiration up to one year after expiration date may submit a late skills verification with their application. 
• Downgrade Statement
  Use this form to apply for lower level of certification.
• Volunteer-to-Paid Status Change
  If you are no longer exclusively a volunteer, you must pay a fee.

Criminal History

Link to criminal history information

• 
  Procedure to Access Criminal History Record Information (CHRI)

• EMS Criminal History Pre-Screening
  This form is intended for evaluating criminal history prior to taking an EMS course todetermineeligibility for EMS certification.
• Criminal History Documentation Guide
  The guide will explain how to complete the following forms:
  • Criminal History Report
    This form is intended for certified/licensed EMS to self-report an arrest, indictment, charge, conviction, deferred adjudication community supervision, and/or deferred disposition.
  • Work History
    Include your current employer and any EMS providers/First Responder organizations you are affiliated with on the form as a paid or volunteer employee.
  • Community Supervision
    This form is used to determine if the Emergency Medical Service (EMS) applicant/certificant/licensee is compliant with his or her community supervision/probation requirements.

EMS Coordinators, Instructors, and Information Operators

Link to educator information.

Use our Online Licensing System to:

• Apply for initial certification.
• Renew
• Address Change
• Print certificate and ID

General Forms

• Educator Fee Exemption
• Surrender of EMS Certificate or License
  Use this form tosurrender your EMS Instructor or Coordinator certificate, EMS Initial Education Program, or EMS Continuing Education Program.

Education Programs

Link to education programs information.

Courses

• Course Notification Checklist
• Notification/Change

Initial Education Programs

• Initial Application Checklist
• Renewal Application Checklist
• Notification/Change
• EMS Education Program Agreement List

Continuing Education Programs

• Initial Application Checklist
• Renewal Application Checklist
• Notification/Change

Link to provider information.

Applications

• Provider Licensing Application

Use our Online Licensing System to:

• Renew

Administrator of Record

• Administrator of Record Initial Application
• Administrator of Record Renewal Application
• Surrender of EMS Certificate or License
  Use this form tosurrender your Administrator of record (AOR) recognition.

Checklists

Use the following checklist as a guide regarding required documentation and elaboration of each provider licensing requirement.

• EMS Provider Initial License Checklist
• EMS Provider Renewal License Checklist
• EMS Provider Initial Survey Checklist
• EMS Provider Survey FAQs
• EMS Quality Assurance Plan Tool
• Virtual Inspections/Surveys Procedure

Forms

• EMS Provider Declaration
• EMS Personnel
• EMS Station Location List
• EMS Headquarters Physical Location Change
• EMS Vehicles
• Subscription Program Surety Bond
• Medicaid Surety Bonds for Ambulance Providers
• Medical Director
• Notifications/Changes
• Replacement License/Authorization
• Variance Request

Links

• Find the nearestregional office.
• EMS Patch Information
• Public Records
• Child Abuse Reporting Requirements
• EMSC Resources
• Out-of-Hospital DNR Forms
• Bloodborne Pathogen Reporting Forms
• Clinical Laboratory Improvement Amendments (CLIA)
  The Centers for Medicare & Medicaid Services (CMS) regulates all laboratory testing (except research) performed on humans in the U.S. through the Clinical Laboratory Improvement Amendments (CLIA). EMS Providers are responsible for securing and maintaining a current CLIA Certificate of Waiver. This applies to any firm using glucometers or other devices to test blood or other patient fluids. Find more information from:
  • Texas Health and Human Services
  • Centers for Medicare & Medicaid Services (CMS)

Link to FRO information.

Applications

Use our Online Licensing System to:

• Apply for initial certification.
• Renew

Checklists

• Initial License
• Renewal License

Forms

• Administrator Information
• Medical Director Information
• Personnel
• Notification/Change

Link to maternal designation information.

Applications

• Complete Application for Level I Designation
• Complete Application for Level II-IV Designation

Forms

• Level I Self-Survey Report
• Level I Sample Attestation
• Facility Program Contact Update

Link to neonatal designation information.

Applications

• Complete Application for Level I Designation
• Complete Application for Level II-IV Designation

Forms

• Level I Self-Survey Report
• Level I Sample Attestation
• Facility Program Contact Update

Link to stroke designation information.

Applications

• Complete Application for All Levels

Forms

• Facility Program Contact Update

Link to trauma designation information.

Applications

• Complete Application for All Levels

Forms

• Facility Program Contact Update

Email reports to: CMUReg.svcs@dshs.texas.gov.

• RAC Performance Criteria
• RAC Self-Assessment with Scoring Tool
• RAC Annual Report Form
• B-13 template
• Board Responsibilities Attestation Form
• EMS Provider Expenditure Report
• EMS Distribution Report
• Quarterly Support Documentation