A.
An owner applying for initial designation shall
submit to the Department an application including:
1. An application form provided by
the Department containing:
a.
The name, address, and main telephone number of the
health care institution for which the owner seeks designation;
b.
The owner's name, address, and telephone number and,
if available, fax number and e-mail address;
c.
The name and telephone number and, if available, fax
number and e-mail address of the chief administrative officer for the health
care institution for which the owner seeks designation;
d.
The designation Level for which the owner is
applying;
e.
If the owner holds verification for the health care
institution for which designation is sought, the Level of verification held and
the effective and expiration dates of the verification;
f.
The asserted basis for designation:
i. The owner holds verification
for the health care institution,
ii. The owner's health care
institution meets the state standards, or
iii. The owner is eligible for the
grace period under
R9-25-1303 ;
g. Unless the owner is an
administrative unit of the U.S. government or a sovereign tribal nation, the
hospital or health care
institution license
number for the health care institution for which designation is
sought;
h. If applying for designation as
a Level I, Level II, or Level III trauma center, the name and telephone number
and, if available, fax number and e-mail address of the health care
institution's trauma medical director;
i. The name, title, address, and
telephone number of the owner's statutory agent or the individual designated by
the owner to
accept service of process and
subpoenas;
j. Attestation that the owner
knows all applicable requirements in A.R.S. Title 36, Chapter 21.1 and this
Article;
k. Attestation that the
information provided in the application, including the information in the
documents attached to the
application form,
is accurate and complete; and
l. The dated signature
of:
i. If the owner is an individual,
the individual;
ii. If the owner is a corporation,
an officer of the corporation;
iii. If the owner is a
partnership, one of the partners;
iv. If the owner is a limited
liability company, a manager or, if the limited liability company does not have
a manager, a member of the limited liability company;
v. If the owner is an association
or cooperative, a member of the governing board of the association or
cooperative;
vi. If the owner is a joint
venture, one of the individuals signing the joint venture
agreement;
vii. If the owner is a
governmental agency, the individual in the senior leadership position with the
agency or an individual designated in writing by that individual;
and
viii. If the owner is a business
organization type other than those described in subsections (A)(1)(l)(ii)
through (vi), an individual who is a member of the business
organization;
2.
Unless the owner is an administrative unit of the
U.S. government or a sovereign tribal nation, a copy of the current regular
hospital or health care institution license issued by the Department for the
health care institution for which designation is sought;
3.
If applying for designation based on verification,
documentation issued by ACS establishing that the owner holds current
verification for the health care institution at the Level of designation sought
and showing the effective and expiration dates of the verification;
and
4.
If applying for designation as a Level I, Level II,
or Level III trauma center based on meeting the state standards, current
documentation issued by ACS establishing that the owner's health care
institution meets the state standards listed in Exhibit I for the Level of
designation sought.
B.
The Department shall process an application as
provided in
R9-25-1315 .
C.
The Department shall approve designation if the
Department determines that an owner is eligible for designation as described in
R9-25-1302 .
A. An owner applying for initial designation
or to renew designation for a health care institution shall submit to the
Department an application including:
1. The
following information, in a Department-provided format:
a. The name, address, and telephone number of
the health care institution for which the owner is requesting
designation;
b. The owner's name,
address, e-mail address, telephone number, and, if available, fax
number;
c. The name, e-mail
address, telephone number, and, if available, fax number of the chief
administrative officer, as defined in A.A.C.
R9-10-101, for the
health care institution for which the owner is requesting
designation;
d. The designation
Level for which the owner is applying;
e. Whether the owner is requesting
designation for the health care institution based on:
i. Verification, or
ii. Meeting the applicable standards
specified in
R9-25-1308 and Table 13.1;
f. If
the owner is requesting designation for the health care institution based on
verification:
i. The name of the national
verification organization;
ii. The
name, telephone number, and e-mail address for a representative of the national
verification organization;
iii. The
Level of verification held;
iv. The
effective date of the verification, and
v. The expiration date of the
verification;
g. If the
owner is requesting designation for the health care institution based on the
health care institution meeting the applicable standards specified in
R9-25-1308 and Table 13.1:
i. Whether:
(1) A national verification organization has
assessed the health care institution, or
(2) The Department will be assessing the
health care institution;
ii. If a national verification organization
has assessed the health care institution:
(1)
The name of the national verification organization;
(2) The name, telephone number, and e-mail
address for a representative of the national verification organization;
and
(3) The date the national
verification organization assessed the health care institution; and
iii. If the Department will be
assessing the health care institution, the date the health care institution
will be ready for the Department to assess the health care
institution;
h. Unless
the owner is an administrative unit of the U.S. government or a sovereign
tribal nation, the license number, issued by the Department, for the health
care institution for which designation is being requested;
i. The name, e-mail address, telephone
number, and, if available, fax number of the health care institution's trauma
program manager;
j. Whether the
health care institution's trauma registry will be located at the health care
institution or be part of a centralized trauma registry;
k. The name, e-mail address, telephone
number, and, if available, fax number of the health care institution's trauma
registrar;
l. If applying for
designation as a Level IV trauma center, whether the health care institution
plans to submit, in addition to the information required in
R9-25-1309(A), the
information specified in
R9-25-1309(B);
m. If not already submitting trauma registry
information to the Department, the time period for which the health care
institution plans to begin submitting trauma registry information;
n. Except for a health care institution
applying for designation as a Level IV trauma center, the name, e-mail address,
telephone number, and, if available, fax number of the health care
institution's trauma medical director;
o. The name, title, address, and telephone
number of the owner's statutory agent or the individual designated by the owner
to accept service of process and subpoenas;
p. Attestation that:
i. The owner will comply with all applicable
requirements in A.R.S. Title 36, Chapter 21.1 and this Article; and
ii. The information and documents provided as
part of the application are accurate and complete; and
q. The dated signature of the applicable
individual according to
R9-25-102;
2. If applicable, documentation demonstrating
that the health care institution is operating as a hospital or an outpatient
treatment center providing emergency services under federal or tribal law as an
administrative unit of the U.S. government or a sovereign tribal nation;
and
3. One of the following:
a. Documentation from the national
verification organization, identified according to subsection (A)(1)(f)(i),
establishing that the owner holds verification for the health care institution
at the Level of designation being requested and showing the effective date and
expiration date of the verification;
b. Documentation from the national
verification organization, identified according to subsection (A)(1)(g)(ii)(1),
demonstrating that the health care institution meets the applicable standards
specified in
R9-25-1308 and Table 13.1; or
c. The
information and documents required in
R9-25-1307(C), (D), or (F), as
applicable.
B. An owner applying to renew designation for
a health care institution shall submit the application in subsection (A) to the
Department at least 60 calendar days and no more than 90 calendar days before
the expiration of the current designation.
C. Within 30 calendar days after receiving an
application submitted according to subsection (A), the Department shall review
the application submitted for completeness, and, if the application is:
1. Incomplete, provide to the owner a written
notice listing each missing item and the information or items needed to
complete the application; and
2.
Complete and based on:
b. A national verification organization
assessing the health care institution's meeting the applicable standards
specified in
R9-25-1308 and Table 13.1, comply with
R9-25-1307(B);
or
c. The Department assessing the
health care institution's meeting the applicable standards specified in
R9-25-1308 and Table 13.1, assess compliance with applicable requirements in A.R.S. Title
36, Chapter 21.1 and this Article according to
R9-25-1307(E)
or (G).
D. The Department shall consider an
application withdrawn if an owner:
1. Fails to
submit to the Department all of the information or items listed in a notice of
missing items within 60 calendar days after the date on the notice of missing
items, unless the Department and the owner agree to an extension of this time;
or
2. Submits a written request
withdrawing the application.
E. If an owner submits an application for
renewal of designation for a health care institution according to subsection
(A) before the expiration date of the current designation, the designation of
the health care institution remains in effect until the:
1. Department has determined whether or not
to issue a renewal of the designation, or
2. Application is withdrawn.
