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Emergency Medical Services Provision in Washington State

This page provides an overview of emergency medical services (EMS) provision for local governments in Washington State, including major statutes and examples of interlocal agreements.


Emergency medical services (EMS) in Washington can be provided by city fire departments, regional fire service authorities, fire districts, public hospital districts, and private ambulance services. EMS is defined in RCW 18.73.030(10) to include “medical treatment and care which may be rendered at the scene of any medical emergency or while transporting any patient in an ambulance to an appropriate medical facility, including ambulance transportation between medical facilities.”

State Regulation

Ch. 70.168 RCW requires the establishment of a statewide EMS and trauma care system and RCW 70.168.015(8) requires the plan for this system be updated every two years.

As part of this plan, the state is divided into eight EMS and trauma care planning and service regions. RCW 70.168.100 creates regional emergency medical services and trauma care councils and RCW 70.168.120 provides that a county or group of counties may create a local and regional emergency medical services and trauma care council.

The state sets the standards and regulates EMS providers under Ch. 18.73 RCW (Emergency Medical Care and Transportation Services) and licenses all ambulance and aid services and vehicles. Aid services must be consistent with the statewide and regional EMS/trauma care plans and approved patient care procedures (See Department of Health EMS and Trauma Care Clinical Guidelines for more information). Cities and towns may impose a business fee on ambulance and aid services operating in their jurisdictions but not a license fee.

Ch. 246-976 WAC (EMS and Trauma Care Systems) establishes criteria for:

  • training and certification of basic, intermediate, and advanced EMS technicians
  • licensure and inspection of ambulance and aid services;
  • development and operation of a statewide trauma registry;
  • verification process and operating requirements for trauma care services; and
  • administration of the statewide EMS/trauma care system.

Authority for Local Governments to Provide Ambulance and Emergency Medical Services

Cities and Towns

  • RCW 35.21.762 — Authorizes the formation of an urban EMS district for cities and towns whose territory is included in two counties, under certain circumstances.
  • RCW 35.21.770/35A.11.110 — Provides that upon adoption by a two-thirds vote of the full legislative body, the legislative body of a city or town may authorize any of its members to serve as volunteer ambulance personnel and may receive the same compensation, insurance, and other benefits received by others.
  • RCW 35.21.766 — Provides for establishment of a regional fire protection service authority and/or ambulance services to be operated as a public utility where existing services are not adequate.
  • RCW 35.21.768 — Authorizes a city or town to adopt: (1) a business and occupation tax on the privilege of engaging in the ambulance business; and/or (2) an excise tax on all persons, businesses, and industries served and billed for the ambulance service owned and operated or contracted for by a city or town.
  • RCW 35.23.456 — Provides second-class cities with the power to operate a municipal ambulance service where commercial ambulance service is not readily available.
  • RCW 35.27.370(15) — Authorizes towns to operate ambulance services for the town and surrounding rural areas and to charge for such service.


  • RCW 36.01.095 — Authorizes counties to establish an EMS system.
  • RCW 36.01.100 — Authorizes counties to establish a system of ambulance service for all or part of a county and to award contracts for that service, provided the service does not compete with an existing private system.
  • RCW 36.32.470 — Provides authority for counties to furnish financial or other assistance to any municipal corporation or political subdivision for fire protection, ambulance, medical, or other emergency services provided by such corporation or subdivision.

EMS Districts

  • RCW 36.32.480 — Provides authority for counties to establish for EMS districts governed by county or by interlocal cooperation agreement if a city or town is included within the district.
  • RCW 41.24.330 and .340 — Provides for a board of trustees for EMS districts under Title 41, Volunteer Fire Fighters' And Reserve Officers' Relief and Pensions.

Fire Protection Districts (FPD)

  • RCW 52.02.020 — Authorizes formation of an FPD for provision of fire protection services, fire suppression services, EMS, and for the protection of life and property; authorizes FPDs to provide training, expend resources, and enter into interlocal agreements to mitigate injuries and reduce level of harm and occurrents in calls they respond to.
  • RCW 52.12.131 — Authorizes FPDs to make reasonable charges for EMS in order to reimburse the district for the costs of providing these services.
  • RCW 52.12.031(4) — Authorizes an FPD to contract with any governmental entity under Ch. 39.34 RCW or private person or entity to consolidate, provide, or cooperate for emergency medical purposes.
  • RCW 52.12.135 — Authorizes a rural FPD to contract pursuant to Ch. 39.34 RCW with a contiguous city to furnish ambulance services. The FPD may impose a monthly utility service charge on each developed residential property located in the portion of the FPD district served pursuant to the contract. An FPD may contract with the contiguous city or with any other governmental entity pursuant to Ch. 39.34 RCW for billing and collection services related to the monthly utility service charge for ambulance service. The city may charge households reasonable rates for use of the service.

Regional Fire Protection Service Authority (FPSA)

  • RCW 35.21.766 (1) — Provides that a regional FPSA may establish a system of ambulance service to be operated as a public utility, which may then contract with cities and counties.
  • RCW 52.26.040(3)(b) — Provides that a regional FPSA planning committee adopt a plan that includes a system of ambulance service to be operated by the authority or operated by contract after a call for bids, if members of the authority are not adequately served by existing private ambulance service

Public Hospital Districts

  • RCW 70.44.007 — Defines health care facilities and authorizes public hospital districts to offer ambulances and ambulance services.

Authority for Emergency Medical Service Tax Levies

  • RCW 84.52.069 — Provides authority for county, emergency medical service district, city or town, public hospital district, urban EMS district, and a regional FPSA or FPD to impose property tax levies for emergency medical care and services.

Court Decisions

The 2004 Washington State Supreme Court ruling in Arborwood, Idaho, L.L.C. v. City of Kennewick, 151 Wn.2d 359, addressed the ability of cities to offer ambulance or EMS services.

Prior to this ruling, 12 Washington cities had funded their ambulance utilities with a monthly fee per household, per RCW 35.21.766. The court ruled that this monthly charge was a tax rather than a fee, and that this fee exceeded the taxing authority granted to cities under RCW 35.21.768

As a result of Arborwood, RCW 35.21.766 was amended in 2005, giving cities the right to establish ambulance utilities through a required process. The first step in the process is that a city council must find that existing private ambulance services operating within the city are inadequate according to acceptable medical standards and reasonable levels of service. The city must then give any private ambulance service operating within its jurisdiction 60 days to meet the standards. Provided the private service cannot meet these standards, the city must move to step two: conducting a cost-of-service study on ambulance rates and charges. 

As part of the cost-of-service study, costs must be separated into “availability costs” and “demand costs.” Availability costs include those for dispatch, labor, training, equipment, and supplies — in other words, costs that are incurred in order for an ambulance service to be ready to respond to a call. Demand costs are those are incurred when responding to an individual call for ambulance service, and these costs vary with frequency of call, distance to hospitals, etc. Ambulance fees are set by spreading availability costs over all classes of service and adding demand costs for each separate class.

 Additional requirements for city-led ambulance services include: (1) establishment of fee exemptions for those who are Medicaid-eligible and who reside in a nursing home, boarding home, adult family home, or who receive in-home services; (2) continued allocation by cities that had utilities prior to May 5, 2004, of at least 70% of general fund dollars they were expending at that time toward the total costs of the utility; (3) support from the general fund and/or EMS levy funds of 70% of the total costs of the utility for cities that established a utility on or after May 6, 2004; and (4) allocation of revenues received from direct billing toward the demand-related costs.

Financing Public Emergency Services and Service Delivery

Local governments offering EMS and ambulance services delivery can fund these services in a variety of ways including charging fees, levy funds, or establishing an ambulance utility.  A local government may also use general fund support or partner to provide emergency services to other local governments through an interlocal agreement.

Levy Funds

RCW 84.52.069 allows local governments (county, EMS district, city or town, public hospital district, urban EMS district, regional FPSA, or FPD) to impose a property tax of up to $0.50 per $1,000 assessed value for emergency medical services via a voter-approved levy. For more information, see our page on EMS Levies.

Ambulance Utility

Amended in 2005 by Ch. 482, Laws of 2005 (ESHB 1635), RCW 35.21.766 provides legislative authority to cities or towns to establish an ambulance utility or a fee structure that can fund ambulance transport services, as set by the governing body. In 2008, the Joint Legislative Audit and Review Committee (JLARC) conducted a Review of Ambulance Utilities as required by the Washington State Legislature. This report reviews the operational status and rates of existing utilities and whether they were established in accordance with generally accepted rate-making practices.


RCW 36.32.480 allows a county to establish an EMS district with the county legislative authority as the governing body of the EMS district if it is operated only within that county. If the EMS district includes a city or town, it may be governed by an interlocal agreement adopted pursuant to Ch. 39.34 RCW. Our List of Emergency Medical Service Providers webpage offers examples of such partnerships.

Many jurisdictions obtain EMS services through a variety of interlocal cooperation arrangements. A city may contract with a fire district or vice versa. In many instances, cities and towns will assess a levy for EMS services and then contract with another jurisdiction or a private entity to provide EMS services. A number of areas have regional providers that may create interlocal agencies to provide the EMS services. In some cases, a combination of both public and private EMS services are used.

Our List of Emergency Medical Service Providers webpage offers examples of different types of partnerships across the state.

Sample Agreements and Other Documents

Clark County

King County

  • Medic One/EMS — Provides regional emergency services to all of King County, except the City of Seattle, whose services are coordinated through the Seattle Fire Department. The webpage includes community programs, strategic planning and data, and other various services such as basic life support training. 

Skagit County

  • Skagit County EMS Department — Monitors the performance of contracted county EMS providers, facilitates a standardized countywide patient care reporting system, and provides a standardized EMS ongoing training and evaluation program.
  • Ordinance No. O20180008 (2018) — Creates a fire-based countywide EMS system and dissolves the Central Valley Ambulance Authority.

Thurston County

Whatcom County

  • Whatcom County EMS — Coordinates county-wide basic and advanced life support and mobile response through a regional partnership of emergency care providers, including fire districts and departments across the county that employ emergency medical technicians and paramedics. 
  • Whatcom County Code Ch. 3.35 — Establishes a sales and use tax for EMS funding.

Recommended Resources

Washington State Department of Health

Last Modified: January 24, 2023