Fields below marked with an "*" indicates a required field and must be completed prior to form submission.
User Assigned Facility*
User First Name*
User Last Name*
User Email*
User Direct Phone Number* {Format: (XXX) XXX-XXXX}
User Phone Type* ---Office/DeskMobil/Cell
User Position Title*
User Department*
User License/Certification Level*
Are you Authorized/Qualified to Sign an Ambulance Physician Certification Statement ("PCS") Form?* ---Yes, I am a Discharge Planner.Yes, I am a Case Manager.Yes, I am a Social Worker.Yes, I am a Registered Nurse.Yes, I am a Licensed Vocational Nurse.Yes, I am a Clinical Nurse Specialist.Yes, I am a Nurse Practitioner.Yes, I am a Physician's Assistant.Yes, I am a Physician.No, I am not an authorized/qualified PCS Signer.
Authorizing Facility Official's Name Approving You to Serve as A Portal User?*
Authorizing Facility Official's Position Title?*
Authorizing Facility Official's Email?*
By clicking onto the Send button below, I am hereby requesting to be granted user access to the Shoreline Ambulance Portal to place ambulance service requests on behalf of the facility I have indicated herein. The information I have provided is true and correct to the best of my knowledge.
Upon submission of this form, you will receive an auto-generated reply-email to confirm receipt of your request. The information will also include the information you have provided herein for your record. upon approval of your request, you will receive a second email indicating User approval with instructions on how to access the portal.
Thank you for your interest in the Shoreline Ambulance Portal.
