Purpose: This form is to be completed and submitted by licensed life support agencies. It is used for requesting privileges from the Medical Control Authority (MCA) under the following circumstances:
- For all new employees.
- When an existing employee changes their licensure level.
- When removing an employee from active status or employment.
Important: This form is strictly for agency use. Individual EMS providers should not submit privileging requests for themselves.
Privileging Policy: Privileging is governed by the Medical Control Privileges Protocol. Ensure you are familiar with this protocol before completing the form. All protocols can be accessed on the MCA website at www.wmrmcc.org/Protocols.
Pre-Submission Checklist:
- Verify Licensing: Ensure that the EMS provider’s State of Michigan EMS license is current and valid.
- Background Check: Confirm that a criminal background check, including a sex offender registry check, has been completed and is on file.
- CPR Certification: Ensure that the provider has a valid Basic Cardiac Life Support (CPR) certification.
Instructions:
- Complete All Required Fields: Ensure that all necessary information is accurately entered in the form.
- Upload Required Documents: Attach the required certifications and test verifications as instructed.
- Submit the Form: Once all fields are completed and documents uploaded, submit the form for MCA review.
- Confirmation: You will receive a confirmation email upon successful submission. The MCA will review the request and provide further instructions.
Notification Process:
- Approval: If privileges are approved (provisional or full), an email will be sent to both the agency and the provider. This email will include the terms of the provisional privileges or a congratulatory message for full privileges.
- Denial: If privileges are denied, an email will be sent to both the agency and the provider, outlining the reasons for the denial.
- Request for Additional Information: If additional information is required, both the agency and the provider will receive an email detailing what needs to be clarified or submitted.
- Confirmation of Removal: If a provider is removed from the agency roster, both the agency and the provider will be notified via email. If the removal is due to ethical, moral, or criminal concerns, the MCA must be informed of the reason.