EMS Air Ambulance License Application Packet

Transcription

1 EMS Air Ambulane Liense Appliation Paket Contents: Contents List and Mailing Information...1 Page Appliation Instrutions Cheklist...3 Pages EMS Air Ambulane Liense Appliation... 5 Pages 4. RCW/WAC and Online Web Site Links...1 Page In order to proess your request: Mail your appliation and other douments to: EMS Credentialing PO Box Olympia, WA Contat us: DOH August 2012

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3 Appliation Instrutions Cheklist When your appliation for EMS Air Ambulane Liense is reeived by the Department of Health (DOH), it will be reviewed and you will be notified in writing of any outstanding doumentation needed to omplete the proess. All information should be typed or printed learly in blue or blak ink. It is your responsibility to submit the orret required forms. Indiate type of appliation new, hange of ownership, amended or renewal. FF FF New First time requesting an Air Ambulane liense. Change of Ownership When name of legal owner/operator hanges resulting from the sale of liensed Air Ambulane. Amended Request the addition or elimination of information on the Air Ambulane Liense. Renewal Renew Air Ambulane Liense. Enter your urrent ageny liense number. Chek One: Please hek your legal owner/operator business struture type aording to your Washington State Master Business Liense. 1: Demographi Information: Uniform Business Identifier Number (UBI #): Enter your Washington State UBI #. All Washington State businesses must have UBI #s. City, ounty, and state government departments also have UBI #s. Federal ID Number (FEIN #): Enter your Federal ID Number, if the business has been issued one. Legal Owner/Operator Name: Enter the owner s name as it appears on the UBI/ Master Business Liense. Legal Owner/Operator Mailing Address: Enter the owner s omplete mailing address. Phone and Fax Numbers: Enter the owner s phone and fax number. and Web Address: Enter the owner s and Web addresses, if appliable. Ageny Name: Enter the ageny name as advertised on signs or Web site. Ageny Physial Address: Enter the ageny physial street loation inluding ity, state, zip ode and ounty. Phone and Fax Numbers: Enter the ageny phone and fax number. Mailing Address: Enter the ageny mailing address, if different than physial address. DOH August 2012 Page 1 of 3

4 FF FF FF FF FF 2: Ageny Speifi Information: Level of are provided on a 24-hour basis: Chek whih one applies to you. Requested response area: Identified in the regional plan. Organization Type: Please hek the one organization that best applies to your organization. Response Information: Provide a number for eah EMS ativity. Primary response, first out/first alarm. Seondary response, responding at primary ageny request, 2nd out alarm. First time appliants need not provide this information Personnel Status: Chek whether paid or volunteer and number of EMS personnel that are paid or volunteer. 3: Contat Information: Contat person: Enter the name, phone number, and address of the person who is able to answer questions about ageny liensing, vehile liensing, and ageny personnel assoiation issues. Inlude a Washington State DOH redential number, if appliable. 4: Supervision: Enter name of the County Medial Program Diretor. 5: Additional Information: Legal Owner: List the names, titles, addresses, and phone numbers of the orporate offiers, LLC members or manager, partners, et. Attah additional ompleted pages as neessary. Change of Ownership Information: If appliable, list the previous legal owner name, previous name of ageny, previous servie redential number, effetive date of ownership hange and physial address. Emergeny Medial Vehiles: Provide year, make and model, tail number, atual address of vehile, Rotary or Fixed Wing air ambulane, and FAA Registration number. Emergeny Medial Servies Personnel: Indiate personnel in your organization who will be providing emergeny are, aid or transportation, showing their highest EMS qualifiation (EMT, paramedi, et.) Inlude all EMS personnel who are full or part-time. Attah additional ompleted pages as neessary. General Operation: Provide information regarding the organization s general operation. Attah additional ompleted pages as neessary. 6: Statements and Signatures: The agenies representative must read the affirmation statement thoroughly to ensure the provisions of this setion are understood. Then, print and sign name and enter the date. DOH August 2012 Page 2 of 3

5 You may obtain information for your loal ounil by ontating your loal EMS system or the Regional EMS and Trauma Care Counil administrator. A link is provided below whih will allow you to determine whih region your ounty is in and the other to provide you with regional ounil ontat information. For information about the regional map, please see our website. For information about the Regional Administrator, please see our Website. DOH August 2012 Page 3 of 3

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7 Date Stamp Here EMS Air Ambulane Liense Appliation This is for: New Change of Ownership Amendment Renewal Liense # Chek One Assoiation Corporation Federal Government Ageny Limited Liability Company Limited Partnership Muniipality (City) Muniipality (County) Non-Profit Corporation Sole Proprietor State Government Ageny Tribal Government Ageny Trust Limited Liability Partnership Partnership 1. Demographi Information UBI # Federal Tax ID (FEIN) # Legal Owner/Operator Name Mailing Address City State Zip Code County Phone (enter 10 digit #) Fax (enter 10 digit #) Address Web Address: Ageny Name (Business name as advertised on signs or Web site) Physial Address City State Zip Code County Ageny Phone (enter 10 digit #) Fax (enter 10 digit #) Mailing Address (If different than physial address) City State Zip Code County For Offie Use Only Credential # Date Issued DOH August 2012 Page 1 of 5

8 2. Ageny Speifi Information Level of are provided on a 24-hour basis: BLS ILS ALS Requested response area (as identified in the regional plan): Organization Type (hek one only) City Fire Department City/Fire Distrit Combined EMS Distrit Federal Fire Department Fire Distrit Hospital Distrit Industrial Fire Department Law Enforement Response Information Please provide the number for eah EMS ativity listed below, for your last full alendar year (if appliable, i.e. when hanging the existing type of servie. First time appliants need not provide this information): Muniipal (ity/ounty) Private Volunteer Assoiation Searh & Resue Other Primary Responses Seondary Responses Transports Primary/Seondary Inter-faility Transports Only Personnel Status Are your EMS personnel primarily: (hek one) Paid Volunteer Number of EMS personnel that are: Paid Volunteer 3. Contat Information Contat Person Name WA State DOH Credential # (if appliable) Address Phone (enter 10 digit #) 4. Supervision Name of County Medial Program Diretor 5. Additional Information Legal Owner Information attah additional sheets as needed List names, addresses, phone numbers, and titles of orporate offiers, partners, members, managers, et. Name Address Phone (enter 10 digit #) Title Change of Ownership Information Previous Name of Legal Owner Previous Name of Servie Previous Servie Credential # Effetive Date of Change DOH August 2012 Page 2 of 5

9 Emergeny Medial Vehiles Please provide the following information for all vehiles to be liensed. Vehile loation is the address in whih the vehile is physially loated. Indiate the type of vehile(s): Fixed Wing; Rotary Wing (as defined in RCW and onsistent with ). See our website for the omplete EMS and Trauma Care System Statutes. Please review WAC to ensure your vehiles meet all requirements. See our website for the omplete EMS and Trauma Care System Rules Year Make and Model Tail Number Atual Address of Vehile (if different from page 1) Choose One ( ) Fixed Wing Rotary Wing FAA Registration Number Note: When adding, removing, or hanging the loation of liensed vehiles, it is always neessary to notify the Department of the hange(s). DOH August 2012 Page 3 of 5

10 Emergeny Medial Servies Personnel List all personnel in your organization who will be engaged in providing emergeny are, aid or transportation, showing all healthare provider redentials held (EMT, Paramedi, RN, et.). Inlude all EMS personnel who are full or part-time. Attah additional ompleted pages if you need more spae Keep a opy of this doument on file for inspetion by the Department of Health Healthare Provider Name Credential Number(s) *Credential Type(s) * Registered nurse, paramedi, Physiian, physiian s assistant, respiratory therapist, EMT, et. DOH August 2012 Page 4 of 5

11 General Operation Please desribe the general operation of your ageny; inluding how it will operate in a manner onsistent with WAC , the Regional Plan, and approved Regional Patient Care Proedures. For more information on ageny and vehile liensing see website. Provide an explanation of your: 1. Dispath plan 2. Response plan 3. Response area 4. Type of transport - please irle one: Emergeny, Interfaility, Both, or N/A. 5. Tiered response and rendezvous, if any 6. Bak-up plan to respond (may not apply to agenies doing interfaility transports only) Note: Other servies involved in your response plan must be informed by you that they are partiipants and must agree to that partiipation. Attah additional ompleted pages if you need more spae. Signature I hereby affirm and delare that the information provided on this appliation is true and orret, and that: 1. We operate in a manner that is onsistent with the Regional Plan and pre-hospital patient are proedures. 2. The vehiles identified on Page 3 meet the minimum equipment requirements provided in WAC (Air Ambulane Servies 3. We meet the minimum staffing requirements as identified on Page Our ertified EMS personnel utilize DOH approved Medial Program Diretor (MPD) protools; 5. Our servie meets all FAA regulations; 6. Copies of our urrent (FAR) 14 C.F.R. Part 135 ertifiate, and CAMTS ertifiate are attahed to this appliation; 7. Our Physiian Diretor is a Washington State liensed physiian; 8. We maintain urrent liability insurane overage (opy attahed). Signature of Owner/Operator Date Print Name Print Title DOH August 2012 Page 5 of 5

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13 RCW/WAC and Online Web Site Links RCW/WAC Links Uniform Disiplinary At... RCW Administrative Proedure At... RCW Emergeny Medial Servies and Trauma System RCW... RCW Emergeny Medial Servies and Trauma System RCW... RCW Emergeny Medial Servies and Trauma System WAC... WAC On-line Emergeny Medial Servies and Trauma System...Web Page RCW/WAC and Online Web Site Links August 2012