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MCA Privilege Request and Change Form


This form is intended for use by licensed life support agencies, participating in the WMRMCC, which are requesting MCA privileges for a new employee, an employee who is changing their licensure level, or removing an employee from active status or employment. This form is NOT to be used by individuals to request MCA privileges for themselves.

A condition of MCA privileging is that individuals consent to having a background check performed by the employer or, at it's discretion, the MCA. Completion of this form for a new employee indicates that the individual has consented to a background check.

MCA Privileging is governed by the Medical Control Privileges Policy and addendum.

You will be asked to upload copies of the required certifications, test completion verification and background check results** within this form, if required by your MCA.