Ariz. Admin. Code § R9-25-902 - Application for an Initial Certificate of Necessity (Authorized by A.R.S. Sections 36-2201(11)(h), 36-2204, 36-2232, 36-2233, 36-2234, 36-2236(A), 36-2240)
A. An applicant
for an initial certificate of necessity shall submit to the Department an
application packet that includes:e.3. A plan to provide
temporary ambulance response or transport service to the proposed service area
for a limited time when the applicant is unable to provide ambulance response
or transport service to the proposed service area, including the criteria for
the person providing dispatch to implement the plan;
g.7. Whether the applicant
or the individual acting for the applicant according to
R9-25-102 : i.a. Has ever been
convicted of a felony or a misdemeanor involving moral turpitude,
ii.b. Has
ever had a license or certificate of necessity for a ground ambulance service
suspended or revoked by any state or political subdivision, or
iii.c.
Has ever operated a ground ambulance service without the required certification
or licensure in this or any other state;
a.8. A description of the
proposed service area by any method specified in A.R.S. §
36-2233(E) and
global positioning system data, in a Department-specified format, that would
allow a map to be created that illustrates the proposed service area;
b.12. A projected
Ambulance Revenue and Cost Report covering the first consecutive 12 months of
operation, as specified in
R9-25-909(A);
c.17. A list 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:
e.18. Documentation
supporting the estimate of the number of transports to be provided, as shown in
the Ambulance Revenue and Cost Report, including any proposed ground ambulance
service contract under A.R.S. §
36-2232(A)(1) or
36-2234(M);
f.19. If
the applicant is requesting to establish general public rates, the information
and documents specified in
R9-25-1101(A);
h.24. A
certificate of insurance or documentation of self-insurance required in A.R.S.
§
36-2237(A) and
R9-25-908(A)(1)(a)(i) and
(ii);
i.25. A surety bond if
required under A.R.S. §
36-2237(B);
j.26. The
resume or other description of experience and qualification to operate a ground
ambulance service of the individuals specified according to subsection
(A)(11)(b);
4.28. Any
other documents, exhibits, or statements that the applicant believes may assist
the Director in evaluating the application or any other information or
documents needed by the Director to clarify incomplete or ambiguous information
or documents, such as:
1. The
following information in a Department-provided format:
b.e. The name, title,
address, e-mail address, and telephone number of the following:
d.f. The name, address,
email address, and telephone number of the person providing dispatch for the
ground ambulance service;
e.g. The address, hours of
operation, and, if available, telephone number of each suboperation station
located within the proposed service area;
h.k. A
description of the communication equipment to be used in each ground ambulance
vehicle and suboperation station;
i.m. for each ground
ambulance vehicle proposed to be used by the ground ambulance service, the
manufacturer's name, the year the ground ambulance vehicle was manufactured,
and, if available, the current mileage;
j.n. The number of
ambulance attendants and the type of licensure, certification, or registration
for each attendant;
k.o. The proposed hours of
operation for the ground ambulance service;
l.p. The type of
service;
m.q. The level of
service;
o.u. Attestation that any
information or documents submitted to the Department are true and correct;
and
p.v. The signature of the
individual acting for the applicant according to
R9-25-102 and the date
signed;
a. The legal business or corporate name,
mailing address, physical address if different from the mailing address,
telephone number, facsimile number if any, and e-mail address of the ground
ambulance service;
b. Any other
names by which the applicant is known;
c. If the applicant is a:
i. Governmental entity, the type of
governmental entity; or
ii.
Business organization:
(1) The type of
business organization, and
(2)
Whether the business organization is proprietary or non-profit;
d. A list of all business
organizations or governmental entities affiliated with the applicant, if
applicable, including for each:
i. The legal
name;
ii. The type of business
organization, if applicable; and
iii. Whether the relationship to the
applicant is as a:
(1) Parent
organization,
(2) Subordinate
organization,
(3) Subsidiary
organization,
(4) Member
organization, or
(5) Business
organization related to an ambulance service, ambulance response, or transport
for which a controlling person of the applicant is also a controlling person of
the business organization;
i. Each applicant and individual responsible
for managing the ground ambulance service,
ii. The individual acting for the applicant
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 applicant to
accept service of process and subpoenas for the ground ambulance service;
c. The name, address, and
telephone number of the base hospital or centralized medical direction
communications center for the ground ambulance
service;
h. Whether the applicant has a proposed
deployment plan for the ground ambulance vehicles in subsection (A)(1)(m),
including:
i. Whether the purchase and
deployment of additional ground ambulance vehicles are planned for the first 12
months following the applicant receiving a certificate of necessity;
ii. Whether additional purchases and further
deployment of additional ground ambulance vehicles are planned for the second
12-month-period following the applicant receiving a certificate of necessity;
and
iii. Whether ground ambulance
vehicles will be deployed based on knowledge of the level of service, types of
service provided, and locations of calls;
f. Whether the ground ambulance
service is a corporation, partnership, sole proprietorship, limited liability
corporation, or other;
g. Whether the business entity is
proprietary, non-profit, or governmental;
i. Whether the applicant has a plan for
participating in the implementation of a political subdivision's emergency
preparedness plan;
j. A list of EMS
providers in surrounding service areas with whom the applicant has a back-up
agreement or from whom the applicant has a letter of support;
l. If applicable, a description of traffic
preemption equipment that the applicant plans to use to facilitate movement of
a ground ambulance vehicle through traffic;
r. If the applicant plans
to provide ALS services or critical care services, a description of how the
applicant plans to provide administrative medical direction according to
R9-25-201 and on-line medical direction according to
R9-25-202, including, as
applicable:
i. The name, address, and
telephone number of the base hospital or centralized medical direction
communications center for the ground ambulance service;
ii. The name, address, professional license
number, and telephone number of the physician providing administrative medical
direction; and
iii. The name,
address, professional license number, and telephone number of the physician or
group of physicians providing on-line medical direction;
n. Acknowledgment that the
applicant:
i. Is requesting to operate ground
ambulance vehicles and a ground ambulance service in this
state;
ii. Has received a copy of 9
A.A.C. 25 and A.R.S. Title 36, Chapter 21.1; and
iii. Will comply with the
Department's statutes and rules in any matter relating to or affecting the
ground ambulance service;
s. Whether the applicant agrees to allow the
Department to submit supplemental requests for information under
R9-25-1201(C)(3);
t. Attestation
that the applicant is familiar with the requirements in A.R.S. Title 36,
Chapter 21.1 and this Chapter and will comply with applicable statutes and
rules in any matter relating to or affecting the ground ambulance
service;
2. The following
information about the proposed service area:
a. Where the ground ambulance
vehicles in subsection (A)(1)(i) are located within the applicant's proposed
service area;
b. A statement of the proposed
general public rates;
c. A statement of the proposed
charges;
d. The applicant's proposed
response times, response codes, and response-time tolerances for each scene
locality in the proposed service area, based on the following:
i. The population demographics
within the proposed service area;
ii. The square miles within the
proposed service area;
iii. The medical needs of the
population within the proposed service area;
iv. The number of anticipated
requests for each type and level of ground ambulance service in the proposed
service area;
v. The available routes of travel
within the proposed service area;
vi. The geographic features and
environmental conditions within the proposed service area; and
vii. The available medical and
emergency medical resources within the proposed service area;
a. The square miles within the proposed
service area;
b. Whether a ground
ambulance service currently operates in all or part of the proposed service
area and, if so, a list of the ground ambulance services currently operating in
the proposed service area;
c. The
population demographics within the proposed service area;
d. Any changes in the population since the
last national census;
e. Any change
in the population demographics since the last national census;
f. The medical needs of the population within
the proposed service area;
g. The
number of anticipated requests for each type of service and level of service in
the proposed service area, including the basis for the estimate;
h. The available routes of travel within the
proposed service area;
i. The
anticipated average mileage per transport within the proposed service area,
including the basis for the estimate;
j. The geographic features and environmental
conditions within the proposed service area;
k. The available medical and emergency
medical resources within the proposed service area;
l. The geographic distribution of health care
institutions within and surrounding the service area to which and from which
the ground ambulance service may be transporting patients;
m. A statement of the proposed general public
rates for services provided within the proposed service area;
n. A statement of the proposed charges;
o. The proposed response times and
a compliance percentage, for each scene locality in the proposed service area
and priority that will be assigned by the applicant to a response;
and
p. If planning to provide
interfacility transports within the proposed service area:
i. The response times and compliance
percentages for the interfacility transport of a patient with a time-critical
condition for each scene locality; and
4. Copies of the back-up agreements
supporting the plan in subsection (A)(3) or letters of support specified
according to subsection (A)(1)(j);
5. A plan for orientation and on-going
training of employees;
6. If
applicable, a copy of a plan for implementing deployment of ground ambulance
vehicles as specified in subsection (A)(1)(h), including the timeframe, if
applicable, for the purchase and deployment of additional ground ambulance
vehicles during the first 12 months after receiving a certificate of necessity;
f. Whether a ground ambulance
service currently operates in all or part of the proposed service area and if
so, where; and
3. The following
documents:
9. Documentation for the individual specified
according to subsection (A)(1)(e)(ii) that complies with A.R.S. §
41-1080;
10. A copy of the business organization's
articles of incorporation, articles of organization, or partnership documents,
if applicable;
11. A copy of an
organizational chart, illustrating both:
a.
The relationships in subsection (A)(1)(d) with two levels of supervision;
and
b. At least three levels of
supervision of key individuals operating the ground ambulance service,
including the individuals listed in subsection (A)(1)(e)(i) through
(iii);
13. A written explanation of why the
applicant believes there is a public need for the applicant to receive an
initial certificate of necessity, including:
a. A summary of how the applicant plans to
address the factors in subsection (A)(2) to ensure the provision of quality
patient care,
b. Justification for
the proposed level of service,
c.
Justification for proposed response times or compliance percentage,
and
d. Supporting
documentation;
14. If
available, any study or statistical analysis that examines the need for ground
ambulance service within a service area or proposed service area that:
a. Considers the current or proposed service
area's medical, fire, and police services; and
b. Was created for or adopted by:
i. A political subdivision, or
ii. A local emergency medical services
coordinating system under A.R.S. §
36-2210(1);
15. A summary of the applicant's
financial history, including:
a. Documentation
of capital resources and financial reserves, if applicable, that is available
for the establishment and operation of the ground ambulance service;
and
b. A plan for coverage of
expected and unexpected expenses, including the source and amount of funding
for cash flow from the date the ground ambulance service commences operation
until the date cash flow covers monthly expenses, with supporting
documentation;
16. If the
applicant is intending to bill for services, the method and plan for the
applicant to bill for services;
a. Real
estate,
b. Ground ambulance
vehicles, or
c. Equipment exceeding
$10,000;
d. The source and amount of
funding for cash flow from the date the ground ambulance service commences
operation until the date cash flow covers monthly expenses;
20. If the applicant is proposing charges to
patients under
R9-25-1109, the information
required in
R9-25-1109(A);
22. If using a
contracted person to provide dispatch, a copy of the contract;
23. If the applicant is planning to provide
ALS services or critical care services:
a. A
copy of each current written contract for providing administrative medical
direction,
b. A copy of each
current written contract for providing on-line medical direction, and
c. Proof of professional liability insurance
for personnel providing ALS services or critical care services required in
R9-25-908(A)(1)(a)(iii);
27. If applicable, a
copy of the applicant's plan for participating in the implementation of a
political subdivision's emergency preparedness plan according to subsection
(A)(1)(h), including as applicable:
a. Mass
casualty protocols;
b. The
provision of ambulance response and transport in the event of a local,
state-wide, or national emergency;
c. Description of the applicant's experience
in disaster response command and control structure; and
d. Special situations in the proposed service
area that need to be taken into consideration; and
a. The quality
improvement process, as required in
R9-25-908(K)(2);
b. A plan to collect and submit electronic
patient care reports consistent with
R9-25-908(K)(2)(a);
c. A plan to adopt clinical guidelines and
operating procedures, consistent with national and state guidelines;
d. If applicable, a plan to initiate
guideline-based pre-arrival instructions for all callers accessing 9-1-1 or a
similar system for assistance;
e.
Evidence of regular attendance and participation in meetings of the emergency
medical services council, established according to A.R.S. §
36-2203, or a regional emergency
medical and trauma services system, established according to A.R.S. §
36-2210;
f. Evidence of participation in a
community-level injury prevention program; or
g. Documentation demonstrating that the
service model will be cost effective.
B.
Before an applicant provides ALS, the applicant
shall submit to the Department the application packet required in subsection
(A) and the following:
1. A current written contract for
ALS medical direction; and
2. Proof of professional liability
insurance for ALS personnel required in
R9-25-909(A)(1)(b) .
C.
When requesting a transfer of a certificate of
necessity:
1. The person wanting to transfer
the certificate of necessity shall submit a letter to the Department that
contains:
a. A request that the certificate
of necessity be transferred, and
b. The name of the person to whom
the certificate of necessity is to be transferred; and
2. The person identified in
subsection (C)(1)(b) shall submit:
a. The application packet in
subsection (A); and
b. The information in subsection
(B), if ALS is provided.
1. $100 application
filing fee for an initial certificate of necessity
2. $50 application filing fee for
a transfer of a certificate of necessity.
D. The Department may
approve an application with special limitations or conditions, based on the
best interest of the public.
E. If
the Department approves an application and sends the applicant the written
notice of approval, specified in
R9-25-1201(C)(5), the Department shall issue the certificate of necessity to the applicant,
consistent with A.R.S. §§
36-2233(E) and
36-2234(A):
1. After the applicant has submitted to the
Department for each ground ambulance vehicle to be operated by the ground
ambulance service:
a. An application for
registration of the ground ambulance vehicle that includes all of the
information required according to
R9-25-1001(B)(1);
b. A copy of a current and valid motor
vehicle registration for the ground ambulance vehicle, issued according to
A.R.S. Title 28, Chapter 7, Article 2, or similar statutes in another state;
and
c. Unless the applicant intends
to operate the ground ambulance vehicle only as a volunteer not-for-profit
service, the following fees for each ground ambulance vehicle to be registered:
i. A $50 registration fee, as required under
A.R.S. §
36-2212(D);
and
ii. A $200 ambulance operation
fee, as required under A.R.S. §
36-2240(3);
and
2. When the
certificate of registration for the first ground ambulance vehicle to be
operated by the ground ambulance service is issued.
F. The Department may deny an application
according to A.R.S. §
36-2233 if an applicant:
1. Fails to comply with any provision in
A.R.S. Title 36, Chapter 21.1;
2.
Fails to comply with any provision in this Article or Article 2, 10, or 11 of
this Chapter;
3. Knowingly or
negligently provides false documentation or false or misleading information to
the Department; or
4. 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).
Notes
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No prior version found.