Patient Information & Forms

Notice of Privacy - March 2020

North Central EMS Financial Assistance Policies & Procedures

Facility Transport Forms

If you are a facility wanting to request transportation of a patient, below you will find the various forms required to be submitted into our Communications Center.

Scheduled Transport Fax Request Form

Medicaid Ambulette

Medicaid Ambulance

Medicare/Private Insurance Ambulance Only PCS

Please print the form, fill out all necessary fields, and fax to the following:

419-499-2216