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EMERGENCY MEDICAL SERVICES PROVIDER LICENSE ADMINISTRATOR OF RECORD INITIAL INFORMATION REVISED: 2/12/2024 Submit the completed form to the appropriate address and with the appropriate cover sheet,
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Administrator of record initial is the initial filing that designates the individual or entity responsible for managing and overseeing certain aspects of a record.
The individual or entity who is designated as the administrator of record is required to file the administrator of record initial.
To fill out the administrator of record initial, the designated individual or entity must provide their basic information and acknowledge their responsibilities.
The purpose of administrator of record initial is to clearly designate who is responsible for the management and oversight of certain aspects of a record.
The administrator of record initial must include accurate and up-to-date contact information for the designated individual or entity.
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