WEMSA Community EMS / MIH Network Interest Form

WEMSA Community EMS Network Interest Form
Thank you for your interest in the WEMSA Community EMS Network, in partnership with and powered by Paralign Health. This initiative is designed to connect Wisconsin EMS agencies with opportunities to support high-value, in-home and community-based care through Mobile Integrated Health / Community EMS services.

By completing this short form, your agency can express interest in learning more about how the network works, what participation may look like, and whether it could align with your current or future Community EMS goals. Whether your agency is just beginning to explore Community EMS or already has an established program, this information helps us better understand your current status and follow up with the most relevant next steps.
We are exploring Community EMS as a future serviceWe are currently building our Community EMS programWe have an established Community EMS programOther
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Job Title*
EMS Agency / Company*
Agency Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty:

WEMSA Community EMS Network Interest Form