Quickforms

If you need any of the following forms, click on the name to download them in PDF format. If you need the Adobe Acrobat Reader, please click here:

Forms for Allied employees to use on the job:

Timesheet

HIPAA Form (Health Insurance Portability and Accountability Act)

Daily Status & Medication Security Report Form

Drug Box Exchange Form

Notice to Medicare Beneficiary

Patient Refusal Check List

Patient Refusal Information Sheet

Physician's Medical Necessity Certification Form (This form must be completed and to Allied EMS within 48 hours of transport's scheduled pickup time.)

Medical Miranda Card

Forms for Employee Incident Reporting:

Blood/Body Substance Exposure Form

Interdepartment Occurance/Incident Report

Employee Injury/Illness/Exposure Report

Risk and Safety Forms:

Allied EMS Systems, Inc. Annual Review (Information and Annual Review Test)

Annual Review Post-Test

Incident / Occurance Report

Monthly Safety Checklist

Summary Field Report

Safety Hazard Report

TB Skin Test Report Form

Human Services Forms:

Michigan Department of Human Services 3200 Form for reporting abuse

Contact Michigan Department of Human Services by county here

Disaster Planning Forms

Field Training Manual (complete)

The following four forms are from the Field Training Manual:

Internship Daily Performance Review

Internship Shift Log

Pre-Run Ambulance Training Checklist

Post-Run Ambulance Training Checklist

Physical Agility Exam

Forms for students in Allied EMS Education classes:

Student Clinical Evaluation Form