BLS Albuterol

The Following are required to submit to Lake Plains Community Care Network for Approval:
  • A letter from the EMS agency physician medical director supporting the request and indicating an understanding of their role in the quality assurance process.
  • Medical Director Verification Form (DOH-4362)
  • Written policies and procedures for the storage and maintenance of Nebulized Albuterol that are consistent with applicable Regional and State protocols. These policies and procedures shall include, but not necessarily be limited to the following:
    • Didactic and psychomotor objectives for training of authorized users including who will be authorized to conduct this training
    • Documentation and attendance records of the training of authorized users 
    • A defined quality assurance program, including appropriateness review by the EMS agency and physician medical director;
    • Written policies and procedures for storage of the Nebulized Albuterol,
    • Notice to the EMS agency physician medical director of the use of the Nebulized Albuterol, and
    • Requirements for documentation when the Nebulized Albuterol is used for patient care

Send your forms to:
Attn: BLS Albuterol
Lake Plains Community Care Network, Inc.
575 East Main Street
Batavia, NY 14020