Policies and Procedures
System Forms
  • Letter of Good Standing and CE Report Request

    In order to transfer Primary or Secondary Affiliation from North Region EMS System to another System, NMnrEMSS must send a Letter of Good Standing and Continuing Education report to your new System. Please submit this request  and allow up to 30 days for processing. Submit to EMS System Coordinator Evert Gerritsen via email:
                evert.gerritsen@nm.org

    Click to Download

    License Renewal Request

    To be completed 60 days prior to IDPH expiration if NMnrEMSS is your Primary EMS System:

    1. Pay IDPH fee via online payment platform and PIN number received in the mail

    2. Verify completion of all System Requirements on EMS1 >> My Dashboard >> Assignments >> Credential Training 100%

    3. Complete IDPH EMS Renewal Notice

    4. Download attached form and submit with current copy of AHA CPR Card to your Medical Officer

    Click to Download

    Request for Clarification

    To request clarification of patient care or provider/hospital communication, please download and submit to EMS System Coordinator Evert Gerritsen via email:
                 evert.gerritsen@nm.org

    Click to Download

    NREMT License Renewal Request

    To be completed by March 1 of expiration year

    1. Ensure you are affiliated with Northwestern Medicine Lake Forest Hospital

    2. From My Certification Dashboard follows steps 1, 2, & 3  to input CE hours

      >> Click to watch video

    3. Pay for re-licensure through NREMT website

    4. Email evert.gerritsen@nm.org to notify your file is ready for renewal

Restocking Forms
  • Ambulance Equipment Restock Form

    For ambulance equipment restock, please fill out attached form and submit to EMS System Coordinator Evert Gerritsen via email.

           evert.gerritsen@nm.org

    Please ensure the alternative point of contact listed is a department employee that works weekdays or is a department number with a voicemail account that is checked regularly. 

    Click to Download

    Pharmacy Restocking Form

    For expired medication exchange, or non-transport exchange, please fill out attached form and submit to EMS System Coordinator Evert Gerritsen via email.

           evert.gerritsen@nm.org

    Click to Download

IDPH Forms
  • ...

    For license renewal, a Renewal/Child Support form must be submitted. Download here

    Click to Download

    ...

    Online Payment Portal

    Click to Follow

    ...

    If you are an out-of-state EMS provider needing to apply for your Illinois License, please download and submit. 

    Click to Download

    ...

    If you are unable to complete the required Continuing Education hours by your license expiration, you may file an Extension Request Application with IDPH prior to expiration. 

    Click to Download

    ...

    To request inactive status on your IDPH license, submit form to IDPH and notify NMnrEMSS. 

    Click to Download

    ...

    If your IDPH license has been de-activated and you are ready to reactivate, please complete this form and send a reactivation request to evert.gerritsen@nm.org

    Click to Download

    ...

    In order to provide EMS care for a Special Event, this form must be submitted 45 days prior to the event. 

    Click to Download

    ...

    In order to receive credit for courses completed in-house, an EMS Training Program form must be submitted annually for your department. 

    Click to Download