Request MCA Privileges

This form is intended for use by Life Support Agencies to request clinical privileges for individuals whom they have hired. This form is not to be used by individuals to request MCA Privileges for themselves.

Privileges Request

Agency applying for provider privileging:

Please select the privileging MCA:

New Provider First Name:

New Provider Last Name:

Date of Birth:

EMS License Number:

Date of Hire:

Please run a Criminal History Check before submitting this form. If the history shows any reported items, it must be submitted to the MCA before privileges will be assigned.

Check if a Criminal Background Check has been Completed:

Check if Criminal History had no reported items:

Provider Level Requested:

Secondary Life Support Agency (Other Employer):

Are the individual's required certifications up to date?:

NoYes

Participants in the ID system must update their employee roster to add the new person. The system requires that the qualification for EMS licenses and Emergency Medical Dispatch be entered, at minimum.

Please upload a copy of the required certifications, (if required by your MCA), a copy of the criminal background check and a copy of the state's license verification.:

The best way to do this is to put all of the files needed into a folder, zip it and then attach the zipped file. This progam only allows for a single upload.

MCA's do not all have the same requirements for document submission, so make sure you know the local requirements.

Have you completed the MCA required protocol written test (either in this MCA or another WMRMCC MCA)?:

NoYes

If completed, please upload a copy of your protocol written or practical test completion results.:

Agency Contact Name:

Agency Contact Phone:

Agency Contact Email:

Security Code:

Note: The security code field provided
above is used to control email spam.
Please note that this field is case
sensitive.

Submit

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