HomeMy WebLinkAboutIdaho EMS License Verification RequestIdaho EMS
License Verification Request
AUTHORIZATION TO RELEASE INFORMATION TO THE IDAHO BUREAU OF EMS
Name: __________________________________________
Last First MI
Also Known As: ___________________________
Alias, Maiden, or Nicknames
Social Security Number: _______-_____-______Date of Birth: ____-_____-_____MM DD YYYY
Mailing Address: ___________________________________________________
Street City State Zip
Phone #: (___) ____-______
I hereby authorize the state of ______________________ EMS licensing authority to furnish the information requested.
________________________________________
Certificate/License Number
_________________________
Date Signed
________________________________________________
Signature of Applicant
_________________________
EMS Level
THIS POTION MUST BE COMPLETED BY THE STATE EMS LICENSING AUTHORITY
Certification/License #: _________________
Expiration Date: ____-_____-_____MM DD YYYY
Initial Issue Date: ____-_____-_____MM DD YYYY
Status: _______________________________
National Scope of Practice Level1. STATUS & LEVEL OF CERTIFICATION/LICENSURE
Emergency Medical Responder (EMR)
Emergency Medical Technician (EMT)
Advanced EMT (AEMT)
Paramedic
2.HAS YOUR STATE TAKEN ANY DISCIPLINARY ACTION AGAINST THIS PERSON RESULTING IN A
SUSPENSION, PROBATION, REVOCATION OR DENIAL FOR EMS CERTIFICATION OR LICENSURE?
IF YES, PLEASE DESCRIBE (USE ATTACHMENT IF NEEDED)YES NO
3.IS THIS INDIVIDUAL CURRENTLY UNDER INVESTIGATION BY YOUR AGENCY?
YES NO IF YES, UPON COMPLETION OF INVESTIGATION, PLEASE NOTIFY THE IDAHO EMS BUREAU OF THE OUTCOME
AND ANY DISCIPLINARY ACTION
I hereby certify that the above information is true and correct recorded by this office.
________________________________________
Signature
_________________________________
Name (Print)
________________________________________
Title
________________________________________
Agency
__________
Date
Please email to: EMSPROVLIC@dhw.idaho.gov
Or mail to: Idaho Bureau of EMS
4732 S. Ingalls St
Bldg 668
Boise, ID 83705-5004
REVISED JUNE 2025
Idaho Bureau of EMS | 4732 S. Ingalls St, Bldg 668 Boise, ID 83705-5004 | 208.334.4000