WEMSIS Contacts

Background:

The Department of Health (DOH) requires reporting of EMS Service contact information for matters related to WEMSIS data and reporting. (RCW 246-976-455, 3.d.)

Please Consider:

When completing the form for the first purpose, all information you provide will replace information from previous form submissions or the current list of contacts. Please include all authorized individuals who currently receive reports.

The completion of this form does not automatically generate WEMSIS accounts for authorized data users. Contact WEMSIS@doh.wa.gov to request accounts for individuals named in this form.

I attest that I have the authority to identify and approve the sharing of EMS Service level reports.*

Agree

EMS Service Name/Legal Owner*

For example: Chelan Co. PHD #2

Business name as advertised on signs or website if different from EMS Service name or legal owner.*

For example: Lake Chelan Valley EMS

EMS Service License Number*

(DOH Credentialing Number – Example AMBV.ES.00000000)

EMS Service Legacy Number*

(Example: 42D09)

Your Name*

Your Email*

Are you a licensed or certified health care provider?*

Select

Please identify the person who should be designated as your WEMSIS Administrator.*

WEMSIS Administrator - acts as the primary contact for the department regarding WEMSIS-related communications including those pertaining to data submission, data validity, data quality, account access and reporting.

The WEMSIS administrator may access all patient-level data contained in WEMSIS under their EMS Service. Only WEMSIS administrators and those assigned by them may access WEMSIS Report Writer and view individual patient care records.

WEMSIS Administrator Name

WEMSIS Administrator Email*

Do you want to identify additional WEMSIS EMS Service Level Report Recipients?*

Yes, I would like my EMS service's reports to go to other people.

No, only I should receive reports for my EMS service.

WEMSIS EMS Service Level Reports Recipients

Please identify any additional individual who is authorized to receive EMS Service Level Reports.

EMS Service Level Report Recipients will receive the following reports: Data Submission Report, Data Quality & Completeness Report, Opioid Surveillance Report, and additional reports as developed and disseminated by the WEMSIS Team at the Washington Department of Health.

EMS Service Level Report Recipient Name (1)

EMS Service Level Report Recipient Email (1)

EMS Service Level Report Recipient Name (2)

EMS Service Level Report Recipient Email (2)

EMS Service Level Report Recipient Name (3)

EMS Service Level Report Recipient Email (3)

EMS Service Level Report Recipient Name (4)

EMS Service Level Report Recipient Email (4)

EMS Service Level Report Recipient Name (5)

EMS Service Level Report Recipient Email (5)

I understand EMS Services are responsible for notifying WEMSIS of any changes to information collected in this form as they occur. Report your changes by resubmitting this form with your updated information. Thank you.

Agree

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