Request EMS Event Services

EMS Special Event Request

Requesting Organization/ Group / Person's Name

Mailing Address

Street Address City ZIP / Postal Code

Physical Address (if different)

Street Address City ZIP / Postal Code

Phone

Email

Website

Billing Contact

The billing contact is the person representing the host as the contact person and who will be available for all questions prior to, during, and post event.

Name & Title

Address

Street Address City ZIP / Postal Code

Primary Phone

Cell Phone

Email

On-Site Contact

Contact information for the person who will be on-site and will be the primary contact on the day of the event if different than the event organizer.

Name & Title

Address

Street Address City ZIP / Postal Code

Primary Phone

Email

Event Information & Details

Event Name

Event Location

Event Date

Event Start

:

Event End

:

Event Description

Is this an annual event?

Yes

No

Is this an multi-day event?

Yes

No

If yes, how many days and what is the anticipated attendance?

Type of Request

Dedicated Ambulance: $150/Hr (The Dedicated Ambulance with Advanced Life Support has immediate transporting capabilities.)

Dedicated ECHO Unit: $75/Hr (The Dedicated Advanced Life Support ECHO Unit is staffed with one Paramedic and provides on-site advanced medical care, but not immediate transporting capabilities.)

Non-Dedicated Ambulance/ ECHO Unit: No Charge (A Non-Dedicated Ambulance and/or ECHO Unit would be on site, but if a request for service or 911 call came in, the unit would leave. Our Dispatch will do our best to replenish coverage, but it is not guaranteed.)

Special Request: Event Trailer (This will require additional personnel and advanced planning at least 2-3 months ahead of event.)

Special Request: SRV Utility Response Vehicle (This will require additional personnel and advanced planning at least 2-3 months ahead of event.)

Billing Information

The individual or company requesting services for a dedicated unit will not be invoiced until services are rendered.
Billing demographics are required prior to event coverage.
Non-Dedicated units will not receive an invoice.
Please contact the billing office directly with billing questions (517) 546-6220 or at lcemsbilling@livgov.com

EMS

David Feldpausch
EMS Director

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Your Name*

First Last

Preferred Method of Contact

Phone Number

Email Address*

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Phone

(517) 546-6220

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Hours

Monday – Friday
8:00 a.m. – 5:00 p.m.
Closed County Holidays

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Location

1911 Tooley Road

Howell, MI 48855

Map



Fax

(517) 546-6788

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Emergencies Only

911

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