Ohio Admin. Code 4766-3-18 - Incorporated by reference

(A) "Ambulette Inspection" form or form "EMS 4019" (February, 2017 2021) can be accessed at the division's website at http://www.ems.ohio.gov/medical-transportation-forms.aspx.

(B) The MTLS online system collects and manages information in categories including service details; medical director; call volumes; communication equipment; service areas; contact information; insurance details; vehicle liability; company executives; satellite locations; vehicle information; and facility and vehicle inspection information. MTOs register and create an account to access the MTLS online system and use it to apply for, renew, and manage a medical transportation license.

(B) "Application for Ambulette License" form or form "EMS 4002" (January, 2018) can be accessed at the division's website at http://www.ems.ohio.gov/medical-transportation-forms.aspx.

(C) "Deletion of Vehicle" form or form "EMS 4012" (April, 2016) can be accessed at the division's website at http://www.ems.ohio.gov/medical-transportation-forms.aspx.

(D) "Headquarters Change of Address" form or form "EMS 4004" (April, 2016) can be accessed via the division's website at http://www.ems.ohio.gov/medical-transportation-forms.aspx.

(E)(C) "Periodic Mechanical Safety Report" form or form "EMS 4039" (June, 2017 July 2021) can be accessed via the division's website at http://www.ems.ohio.gov/medical-transportation-forms.aspx.

(F) "Renewal Application for Ambulette License" form or form "EMS 4041" (May, 2018) can be viewed at the division's website at http://www.ems.ohio.gov/medical-transportation-forms.aspx.

(G) "Temporary Ambulette Application" form or form "EMS 4010" (July, 2013) can be accessed via the division's website at http://www.ems.ohio.gov/medical-transportation-forms.aspx.

(H)(D) "Violation Notification" form or form "EMS 4029" (July, 2018 2021) is issued by the board to an ambulette service/non-emergency medical services organization that is in violation of Chapter 4766. of the Revised Code and agency 4766 of the Administrative Code and a sample of the form can be viewed at http://www.ems.ohio.gov/medical-transportation-forms.aspx.

Notes

Ohio Admin. Code 4766-3-18

Effective: 6/15/2022
Five Year Review (FYR) Dates: 3/23/2022 and 03/01/2027
Promulgated Under: 119.03
Statutory Authority: 4766.03
Rule Amplifies: 4766.03
Prior Effective Dates: 08/01/2017, 02/01/2020