New Provider Information

First Name
Middle Initial
Last Name
Last four digits of SSN
Phone
Email
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?
If yes, please attach photo of CE documentation:
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 certifications. If including multiple certifications, submit one photo including all certifications:
Submit (Please click the button only one time.)