Form Center

The county’s Online Form Center allows you to electronically submit and/or print requests for information and other forms. They are organized based on the agency that supports the service. If you experience difficulty finding the information you are looking for, please use the search feature below.
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COVID-19 Emergency Medical Material Request (EMMR) Form

Steps

  1. 1. SECTION 1: Facility Information
  2. 2. SECTION 2: Personal Protective Equipment Request
  • SECTION 1: Facility Information

    1. Emergency Medical Materials Request Form

      Requestor Authorization:


      • I HEREBY CERTIFY THAT THE FACILITY BELOW IS TAKING ALL NECESSARY AND APPROPRIATE MEASURES TO CONSERVE PPE IN BOTH CURRENT SUPPLY AND REQUESTED ALLOCATION ACCORDING TO CDC GUIDANCE.
      • I HEREBY CERTIFY THAT THE FACILITY WILL NOT CHARGE FOR PPE OR OTHER SUPPLIES RECEIVED FROM THE STATE OF MARYLAND OR LOCAL HEALTH DEPARTMENT (EITHER DIRECTLY OR THROUGH A THIRD-PARTY PAYER, SUCH AS INSURANCE).
      • I HEREBY CERTIFY THAT THE FACILITY HAS EXHAUSTED ALL OTHER MEANS OF OBTAINING PPE, TO INCLUDE THE COMMERCIAL SUPPLY CHAIN AND FEDERAL RESOURCES (E.G. DIRECT CARES ACT FUNDING.)
      • I UNDERSTAND THAT THE FACILITY MAY NOT RECEIVE THE TOTAL AMOUNT OF SUPPLIES REQUESTED.

      If you have any questions please email us at CountyEOC@co.pg.md.us and/or kmstinchcomb@co.pg.md.us.

    2. fill in the box above.