New Memorial Health EMS Provider

New Provider Information

First Name

Middle Initial

Last Name

Last 4 of SSN

Verify email address

Select primary agency within Memorial EMS:

Please attach photo of CPR card with expiration date

Please attach photo of IDPH EMS license with expiration date/number

Was your initial IDPH license course after January 1, 2018?

If no, have you completed a bridge course for the Illinois Expanded Scope of Practice?

Level of License (Once Selected it will require the following)

If AEMT/EMT-I or EMT-P/PHRN (check all that apply)

Please attach photo of AEMT/EMT-I or EMT-P/PHRN license. If including multiple licenses, submit one photo including all licenses