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Home My WebLink About2016-721-E Emergency Svc - NC DHHS EMD Center Renewal ApplicationNORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES DEPARTMENT OF HEALTH SERVICE REGULATION OFFICE OF EMERGENCY MEDICAL SERVICES 1201 Umstead Drive | 2707 Mail Service Center | Raleigh, NC 27603-2008 | Phone: (919) 855-3935 | Fax: (919) 733-7021 EMD CENTER RENEWA L A PPL ICA TION Effective: 8/1/2014 This application is for renewal of Emergency Medical Dispatch (EMD) Centers. EMD Centers must be operational twenty-four (24) hours a day, seven (7) days a week. Each highlighted section must be completed. Information in the Credentialing Information System (CIS) must be current prior to application submission. Endorsements from the EMD Center Director, EMS System Administrator, System Medical Director, and County Manager (if applicable) are required. Renewals must be submitted to the appropriate regional EMS office indicated below. GENERAL INFORMATION EMD Center Name: Office Number: Physical Address: Fax Number: City: State:Provider Admin Contact: County: Zip:Title: Mailing Address: Office Number: City: State:MobileNumber: County: Zip:FaxNumber: PROVIDER PROPERTIES E-mail Address: Provider Number: System Affiliation: Renewals must be submitted to the appropriate regional office indicated below: CENTRAL Central Regional Office of EMS 801 Biggs Drive 2717 Mail Service Center Raleigh, NC 27699-2717 Office: (919) 855-4678 Fax: (919) 715-0498 EASTERN Eastern Regional Office of EMS 404 St. Andrews Drive, Suite 7 Greenville, NC 27834-6850 Office: (252) 355-9026 Fax: (2525) 355-9063 WESTERN Western Regional Office of EMS 3305 16th Avenue SE, Suite 302 Conover, NC 28613-9213 Office: (828) 466-5548 Fax: (828) 466-5651 BE PREPARED TO PRESENT SUPPORTING DOCUMENTATION UPON REQUEST EMD Center Renewal Effective 8/1/2014 DHHS/DHSR/OEMS 4917 Page 1 of 3 DocuSign Envelope ID: 0123867B-484A-40EF-9EC6-2607BAF583F8 0680960 919 245-6139 919 245-6100 kmedlin@orangecountync.gov 27278 919 732-8130 Interim 9-1-1 Operations Manager 919 732-5016 Hillsborough Orange County Emergency Services Orange Orange County PO Box 8181 NCKevin Medlin 500 Meadowlands Drive Hillsborough NC Orange NC SECTION .0400 - MEDICAL OVERSIGHT 10A NCAC 13P .0401 COMPONENTS OF MEDICAL OVERSIGHT FOR EMS SYSTEMS Each EMS System shall have the following components in place to assure medical oversight of the system: 10A NCAC 13P .0401(3) for systems providing EMD service, an EMDPRS approved by the medical director. NOTE: Medical Director’s signature is required on this application. 10A NCAC 13P .0403 RESPONSIBILITIES OF THE MEDICAL DIRECTOR FOR EMS SYSTEMS 10A NCAC 13P .0403(a) The Medical Director for an EMS System is responsible for the following: 10A NCAC 13P .0403(a)(3) EMD programs, the establishment, approval, and annual updating of the EMDPRS. DATE OF LAST EMDPRS REVIEW: 10A NCAC 13P .0407 REQUIREMENTS FOR EMERGENCY MEDICAL DISPATCH PRIORITY REFERENCE SYSTEM 10A NCAC 13P .0407(a) EMDPRS used by an EMD within an approved EMD program shall: 10A NCAC 13P .0407(a)(1) be approved by the OEMS Medical Director and meet or exceed the statewide standard for EMDPRS as defined by the "North Carolina College of Emergency Physicians: Standards for Medical Oversight and Data Collection," incorporated by reference in accordance with G.S. 150B-21.6, including subsequent amendments and editions. 10A NCAC 13P .0407(a)(2) not exceed the EMD scope of practice defined by the North Carolina Medical Board pursuant to G.S. 143-514. 10A NCAC 13P .0407(b) An EMDPRS developed locally shall be reviewed and updated annually and submitted to the OEMS Medical Director for approval. Any change in the EMDPRS shall be submitted to the OEMS Medical Director for review and approval at least 30 days prior to the implementation of the change. (EXAMPLE: EMDPRS will be reviewed every January or as changes occur throughout the year.) EMDPRS CARD SET NAME: VERSION NO:EMDPRS LICENSE NO: NOTE: If the EMDPRS is developed locally, please provide a complete copy of card set and assurance that the EMDPRS will be reviewed annually and submit to OEMS Medical Director for approval. VERIFY THE EMD ROSTER LISTED IN THE CREDENTIALING INFORMATION SYSTEM (CIS) IS CORRECT (if no, update in CIS):YES NO BRIEFLY DESCRIBE THE EMD PROGRAM CONTINUING EDUCATION AND RECREDENTIALING REQUIREMENTS TO INCLUDE EDCUATIONAL INSTITUTION AND INSTRUCTOR INFORMATION: VERIFY THEFCC CALL SIGNAND EXPIRATION DATEOF THECENTERTHATWILL BE UTILIZINGTHE EMD PROGRAM INTHE CREDENTIALINGINFORMATIONSYSTEM (CIS) IS CORRECT (if no, update in CIS):YES NO FCC CALL SIGN: EXPIRATION DATE: NOTE: EMD Centers must have representation at Peer Review Committee Meetings. BE PREPARED TO PRESENT SUPPORTING DOCUMENTATION UPON REQUEST EMD Center Renewal Effective 8/1/2014 DHHS/DHSR/OEMS 4917 Page 2 of 3 DocuSign Envelope ID: 0123867B-484A-40EF-9EC6-2607BAF583F8 IAED Medical Priority Dispatch System 90-10620 Monthly con ed through Richmond Community College, as well as regular in-house training based on identified areas found during the Quality Assurance process. Recredentialing is every 2 years, through Priority Dispatch, via an online test and submission of con ed hours. Laura Piche' - NC Sheriffs' Education and Training Standards General Instructor, NC Level I Instructor, EMD-Q 13.0 1/5/2023 KSQ687 EMD CENTER RENEWA L A PPL ICA TION Effective: 8/1/2014 EMDCENTER NAME:________________________________________________ PROVIDER NUMBER:____________________ ENDORSEMENTS We, the undersigned, recommend this EMD Center for renewal by the North Carolina Office of EMS. We fully approve, support, and endorse this application to the North Carolina Office of EMS with thorough knowledge and understanding of our respective roles and responsibilities in maintaining an EMD Center within our EMS System in the State of North Carolina pursuant to the rules of the North Carolina Medical Care Commission. EMDCENTER DIRECTOR Type/Print Name Signature Date EMS SYSTEM ADMINISTRATOR Type/Print Name Signature Date SYSTEM MEDICAL DIRECTOR Type/Print Name Signature Date *COUNTY MANAGE R Type/Print Name Signature Date *The County Manager’s signature is not required when through written delegation or resolution, the system administrator has been delegated authority to act on behalf of the county. If the county manager or system administrator has changed since last submission, a new letter from the county is required. BE PREPARED TO PRESENT SUPPORTING DOCUMENTATION UPON REQUEST EMD Center Renewal Effective 8/1/2014 DHHS/DHSR/OEMS 4917 Page 3 of 3 DocuSign Envelope ID: 0123867B-484A-40EF-9EC6-2607BAF583F8 0680960Orange County Emergency Services Dr. Jane Brice Kevin G. Medlin Bonnie Hammersley Kimberly K. Woodward