A. An applicant for an initial license shall
submit an application packet to the Department, including:
1. The following information in a
Department-provided format:
a. The
applicant's name; mailing address; e-mail address; fax number, if any; and
telephone number;
b. The names of
all other business organizations operated by the applicant related to the air
ambulance service;
c. The physical
and mailing addresses to be used for the air ambulance service, if different
from the applicant's mailing address;
d. The name, title, address, e-mail address,
and telephone number of the applicant's statutory agent or the individual
designated by the applicant to accept service of process and subpoenas for the
air ambulance service;
e. The name,
title, address, e-mail address, and telephone number of the individual acting
on behalf of the applicant according to
R9-25-102;
f. If the applicant is a business
organization:
i. The type of business
organization; and
ii. The name;
address; e-mail address; telephone number; and fax number, if any, of the
individual who is to serve as the primary contact for information regarding the
application;
g. The name
and Arizona license number for the physician who is to serve as the
administrative medical director for the air ambulance service;
h. The intended hours of operation for the
air ambulance service;
i. The
intended schedule of rates for the air ambulance service;
j. Which of the following mission types is to
be provided:
i. Emergency medical services
transports,
ii. Interfacility
transports,
iii. Interfacility
maternal transports, or
iv.
Interfacility neonatal transports;
k. Which of the following mission levels is
to be provided:
i. Critical care,
or
ii. Advanced life
support;
l. Whether the
applicant plans to use fixed-wing or rotor-wing aircraft for the air ambulance
service;
m. Whether the applicant
agrees to allow the Department to submit supplemental requests for information
under
R9-25-1201(C)(3);
n.
Attestation that the applicant will comply with all applicable requirements in
this Article, Articles 2 and 8 of this Chapter, and A.R.S. Title 36, Chapter
21.1;
o. Attestation that the
information provided in the application packet, including the information in
the accompanying documents, is accurate and complete; and
p. The signature of the applicant and the
date signed;
2.
Documentation for the individual specified according to subsection (A)(1)(e)
that complies with A.R.S. §
41-1080;
3. A copy of the business organization's
articles of incorporation, articles of organization, or partnership documents,
if applicable;
4. A copy of a current and valid
U.S. Department of Transportation OST Form 4507, showing the effective date of
Federal Aviation Administration registration and exemption under 14 CFR
298 ;
5. A copy of the following issued
by the Federal Aviation Administration:
a. A current and valid Air
Carrier Certificate authorizing common carriage under 14 CFR
135 ;
b. If intending to operate a
rotor-wing air ambulance, the following signed pages of the current and valid
Operations Specifications authorizing aeromedical helicopter
operations:
i. The page showing the
certificate number issued by the Federal Aviation Administration and stating
the name and contact information for the entity to which the certificate,
approving the Operation Specifications authorizing aeromedical helicopter
operations, was issued by the Federal Aviation Administration;
ii. The page stating the
characteristics of the rotor-wing aircraft for which the certificate was issued
by the Federal Aviation Administration;
iii. Each page stating the name
and contact information for the individuals with controlling legal interest or
controlling equitable interest in the ownership of the entity specified in
subsection (A)(5)(b)(i);
iv. Each page stating the name and
contact information for the individuals designated to act as a point of contact
with the Federal Aviation Administration about the Operation Specifications for
the rotor-wing aircraft;
v. Each page stating the name and
contact information for the individuals with operational control of the
rotor-wing aircraft; and
vi. Each page listing the tail
numbers of the rotor-wing aircraft covered under the Operations Specifications;
and
c. If intending to operate a
fixed-wing air ambulance, the following signed pages of the current and valid
Operations Specifications authorizing airplane air ambulance
operations:
i. The page showing the
certificate number issued by the Federal Aviation Administration and stating
the name and contact information for the entity to which the certificate,
approving the Operation Specifications authorizing airplane ambulance
operations, was issued by the Federal Aviation Administration;
ii. The page stating the
characteristics of the fixed-wing aircraft for which the certificate was issued
by the Federal Aviation Administration;
iii. Each page stating the name
and contact information for the individuals with controlling legal interest or
controlling equitable interest in the ownership of the entity specified in
subsection (A)(5)(c)(i);
iv. Each page stating the name and
contact information for the individuals designated to act as a point of contact
with the Federal Aviation Administration about the Operation Specifications for
the fixed-wing aircraft;
v. Each page stating the name and
contact information for the individuals with operational control of the
fixed-wing aircraft; and
vi. Each page listing the tail
numbers of the fixed-wing aircraft covered under the Operations
Specifications;
6.4. For each aircraft to
be used as an air ambulance by the air ambulance service:
a. An application for registration that
includes all of the information and documents required under
R9-25-801(B);
and
b. A copy of a current and
valid registration, issued by the Arizona Department of Transportation under
A.R.S. Title 28, Chapter 25, Article 4;
7.5. A certificate of
insurance establishing that the applicant has current and valid liability
insurance coverage for the air ambulance service as required under
R9-25-703(B)(3);
8.6. A certificate of
insurance establishing that the applicant has current and valid malpractice
insurance coverage for the air ambulance service as required under
R9-25-703(B)(4);
9.7. A list of each entity
that or physician who is to provide on-line medical direction to EMCTs of the
air ambulance service, including:
a. For each
entity, such as an ALS base hospital, centralized medical direction
communications center, or physician group practice, the name, mailing address,
e-mail address, and telephone number of the entity; or
b. For each physician who is to provide
on-line medical direction, the name, professional license number, mailing
address, email address, and telephone number for the physician;
and
10.8. If the applicant
holds current CAMTS accreditation for the air ambulance service, a copy of the
current CAMTS accreditation report
11. If a document required under
subsection (A)(4) or (5) is not issued in the name of the applicant,
documentation showing the applicant can legally possess and operate the
aircraft covered by the document, signed by the owner of the
aircraft.
B. No more than 30 days before the expiration
date of the current license, a licensee shall submit to the Department a
renewal application packet including:
1. The
information required in subsection (A)(1), in a Department-provided
format;
2. The documents required
in subsections (A)(5), (6), (7), and, if applicable, (8); and
3. For each aircraft used or to be used as an
air ambulance by the air ambulance service:
a. Either:
i. A copy of a current and valid certificate
of registration issued by the Department under Article 8 of this Chapter,
or
ii. An application packet for
registration that includes all of the information and documents required under
R9-25-801(B); and
b. A
copy of a current and valid registration, issued by the Arizona Department of
Transportation under A.R.S. Title 28, Chapter 25, Article
4.
E. The Department may deny an application if
an applicant or licensee:
1. Fails to meet
the eligibility requirements of
R9-25-703(B);
2. Fails or has failed to comply with any
provision in A.R.S. Title 36, Chapter 21.1;
3. Fails or has failed to comply with any
provision in this Article or Article 2 or 8 of this Chapter;
4. Knowingly or negligently provides false
documentation or false or misleading information to the Department;
or
5. Fails to submit to the
Department documents or information requested under
R9-25-1201(B)(1) or (C)(3)
and requests a denial as permitted under
R9-25-1201(E).
