A.
An applicant for a certificate of necessity or a
certificate holder applying for initial general public rates shall submit an
application packet to the Department that includes:
1. The applicant's
name;
2. The requested general public
rates;
3. A copy of the applicant's most
recent financial statements or an Ambulance Revenue and Cost
Report;
4. For a consecutive 12-month
period:
a. A projected income statement;
and
b. A projected cash-flow
statement;
5. A list of all purchase
agreements or lease agreements for real estate, ground ambulance vehicles, and
equipment exceeding $5,000 used in connection with the ground ambulance
service, that includes the monetary amount and duration of each
agreement;
6. The identification
of:
a. Each of the applicant's
affiliations, such as a parent company or subsidiary owned or operated by the
applicant; and
b. The methodology and
calculations used in allocating costs among the applicant and government
entities or profit or not-for-profit businesses;
7. A copy of the applicant's
contract with each federal or tribal entity for ground ambulance service, if
applicable;
8. Other documents, exhibits, or
statements that may assist the Department in setting the general public
rates;
9. An attestation signed by the
applicant that the information and documents provided by the applicant are true
and correct; and
10. Any other information or
documents requested by the Director to clarify or complete the
application.
A. As provided
in
R9-25-902(A)(19), an applicant wanting to establish initial general public rates as part of an
application for an initial certificate of necessity shall include the following
in the application packet submitted to the Department according to
R9-25-902(A) :
1. A copy of the applicant's financial
statements, covering the most recent consecutive 12-month period;
2. A copy of the purchase agreements or lease
agreements listed according to
R9-25-902(A)(17), if not already submitted according to
R9-25-902(A)(28);
3. For all business organizations or
governmental entities affiliated with the applicant listed according to
R9-25-902(A)(1)(d), the methodology and calculations used in allocating costs
among the applicant and government entities or profit or not-for-profit
businesses;
4. Other documents,
exhibits, or statements that may assist the Department in setting the general
public rates; and
5. Any other
information or documents requested by the Director to clarify or complete the
application.
B. A
certificate holder applying for initial general public rates shall submit to
the Department:
1. The following information,
in a Department-provided format:
a. The
identifying number on the certificate holder's current certificate of
necessity;
b. The legal business or
corporate name, address, telephone number, and facsimile number of the ground
ambulance service;
c. Any other
names by which the certificate holder is known;
d. The names of all other business
organizations or governmental entities operated by the certificate holder
related to the ground ambulance service;
e. The name, title, address, e-mail address,
and telephone number of the following:
i. Each
certificate holder and individual responsible for managing the ground ambulance
service,
ii. The individual acting
for the certificate holder according to
R9-25-102 ,
iii. The individual to contact to access the
ground ambulance service's records required in
R9-25-908(B), and
iv. The statutory agent for the
ground ambulance service or the individual designated by the certificate holder
to accept service of process and subpoenas for the ground ambulance
service;
f. The requested
general public rates;
g. Whether
the certificate holder agrees to allow the Department to submit supplemental
requests for information under
R9-25-1201(C)(3);
h. Attestation that the information or
documents submitted to the Department are true and correct; and
i. The signature of the individual acting for
the certificate holder according to
R9-25-102 and the date
signed;
2. A copy of the
certificate holder's financial statements, covering the most recent consecutive
12-month period;
3. A projected
Ambulance Revenue and Cost Report covering the first consecutive 12 months of
operation under the requested general public rates in subsection
(B)(1)(f);
4. A copy of all actual
or anticipated purchase agreements or lease agreements to be used in connection
with the ground ambulance service, including the monetary amount and duration
of each agreement, for:
a. Real
estate,
b. Ground ambulance
vehicles, or
c. Equipment exceeding
$10,000;
5. For all
business organizations or governmental entities affiliated with the certificate
holder listed according to subsection (B)(1)(d), the methodology and
calculations used in allocating costs among the certificate holder and business
organizations or governmental entities;
6. Other documents, exhibits, or statements
that may assist the Department in setting the general public rates;
and
7. Any other information or
documents requested by the Director to clarify or complete the
application.
C. Each
certificate holder requesting to apply for a uniform general public rate under
A.R.S. §
36-2232(E) shall
submit to the Department:
1. The information
required in subsection (B)(1);
2.
The documents required in subsections (B)(4) through (7);
3. A copy of the certificate holder's
financial statements, covering the most recent consecutive 24-month
period;
4. Projected Ambulance
Revenue and Cost Reports covering the first consecutive 24 months of operation
under the requested general public rates in subsection (B)(1)(f); and
5. A document signed by each certificate
holder requesting to apply for a uniform general public rate under A.R.S.
§
36-2232(E).
B.D. The Department
shall review an application under subsection (B) or (C) according to
R9-25-1106,
R9-25-1107, and
R9-25-1201 and approve or deny the application
according to A.R.S. §
36-2232 and Article 12 of this
Chapter.
