Forms

EMS Protocol Forms

• Request to be Taken to a Hospital on Diversion
• Thrombolytic Checklist - STEMI
• Thrombolytic Checklist - Stroke

Miscellaneous

• Alabama Order for Pediatric Palliative and End of Life Care
• Alabama Order for Pediatric Palliative and End of Life Care (Spanish)
• Alabama Portable Physician Do Not Attempt Resuscitation (DNAR) Order
• Alabama Portable Physician Do Not Attempt Resuscitation (DNAR) Order (Spanish)
• Authorization for Release of Protected Health Information
• Essential Job Functions Analysis Form
• Information Update Form

Pursuant to a Final Rule effective December 23, 2024, to modify the Health Insurance Portability and Accountable Act of 1996 (HIPAA) Privacy Rule to support reproductive health care privacy, the Department must obtain a signed attestation. By signing this attestation, you are verifying that you are not requesting protected health information (PHI) for a prohibited purpose and acknowledge that criminal penalties may apply if untrue. Clack here for the form.

For General Records Requests please refer to ADPH Public Record Requests.

Compliance

• Ambulance Accident Form
• Complaint Form

Provider Services

• Web Management Form