BREMSS BLS Agency Information

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Today's Date *

County of Operation *

Name of Provider *

Physical Address

Street Address *

City *

State *

Zip *

Mailing Address

Same as Physical Address

Mailing Address

City

State

Zip

Contact information

First name

Last name

Email *

Business Phone

Emergency Phone

Quality Assurance

Same as Contact Person

QA/QI Contact Person

QA/QI Phone

QA/QI Email

Communications

Primary Communication Method

Secondary Communication Method

Other Communication Methods

Insurance Information

Insurance Carrier

Insurance Phone

Insurance Address

BLS Vehicles

BLS Response Vehicles

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Personnel

Personnel Roster

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Medical Director

Physician Name

Hospital Affiliation

Alabama License #

MCID #

Dispatch Information

Dispatch Agency Name

Dispatch Phone 1

Dispatch Phone 2

Medical Direction Hospital Information

Medical Direction Hospital

Hospital City

Hospital State

Hospital Contact

Hospital Phone

Hospital Email

Registration fees

Registration to this event

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