AIR MEDICAL SERVICE. City State Zip

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Loraine Stokes
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1 INITIAL REVIEW ANNUAL AUDIT - YEAR TENNESSEE DEPARTMENT OF HEALTH DIVISION OF HEALTH LICENSURE AND REGULATION OFFICE OF EMERGENCY MEDICAL SERVICES 665 MAINSTREAM DRIVE, 2 ND FLOOR NASHVILLE, TN TELEPHONE: (615) AIR MEDICAL SERVICE Helicopter Fixed Wing : Air Ambulance Service: Air Ambulance Service Address: Street City State Zip Telephone No.: ( ) Fax No.: ( ) Address: Name of Air Ambulance Service Director of Record: Working Title: Region: Regional Consultant: Name of Service Personnel Present: VERIFY CURRENT FAA LICENSE INFORMATION Certificate Number: Effective : Part 135: Yes No Part 91 only: Yes No MEDICAL DIRECTOR QUALIFICATIONS Rule (5) (a) Medical Directors Name: Medical Directors Address: Currently Licensed In State of Tennessee Board Certified or Eligible: General or Trauma Surgery, Family Practice, Internal Medicine, Pediatrics, Emergency or Aerospace Medicine ACLS or Eligible for Board Certification in Emergency Medicine ATLS and PALS or Neonatal Resuscitation Program and Knowledge Regarding Altitude Physiology/Stressors of Flight (Unless Board Certified or Eligible for Board Certification in Emergency Medicine) PH-4243 (7/2014) Page 1 of 5 RDA

: ( ) E-Mail Address: Name of Air Ambulance Service Director of Record: Working Title: Region: Regional Consultant: Name of Service Personnel Present: VERIFY CURRENT FAA LICENSE INFORMATION

2 PERSONNEL QUALIFICATIONS Rule (5) (c) Check Training Records To Complete Attached Log OPERATIONS MANUAL FOR FLIGHT CONTROL OFFICE Rule (6) Medical Indications and Contraindications for Flight Call Verifications Procedures and Advisories Radio and Telephone Notification Post Accident / Incident Plan Communication Failure Overdue Transports Downed Aircraft Search and Rescue Requesting Party Briefing for Arrival and Termination Any Deviation of ETA Greater Than 5minutes DISPATCH RECORDS Flight Number Type of Mission Aircraft Number Flight Crew and Passengers Origin Destination PH-4243 (7/2014) Page 2 of 5 RDA

Plan Communication Failure Overdue Transports Downed Aircraft Search and Rescue Requesting Party Briefing for Arrival and Termination Any Deviation of ETA Greater

3 Referring and Receiving Doctor and Significant Times Requesting Agency and Contact Person PATIENT RECORDS Rule (9) An Appropriate Sample Of Reports Will Be Reviewed To Substantiate Completion Of Patient Records Patients Name of Transport Documentation of Treatment Origin Destination of Flight Type of Mission Medical Personnel Ground Service Accessible Chief Complaint CONTINUOUS QUALITY IMPROVEMENT Rule (10) (11) Utilization Review Quality Improvement REVIEW OF FLIGHT INFORMATION Rule (9) (a) 2 Number of Transfers: Time Period: From To PH-4243 (7/2014) Page 3 of 5 RDA

Origin Destination of Flight Type of Mission Medical Personnel Ground Service Accessible Chief Complaint CONTINUOUS QUALITY IMPROVEMENT Rule 1200-12-01-.

4 INSTRUCTION MATERIALS FOR EMS PROVIDERS WITHIN RESPONSE AREA (HELICOPTER ONLY) Rule (4) Printed Material to Include: Control of Helicopter Access Ground to Air Communications on the Scene AIR MEDICAL COMMUNICATION SPECIALIST (HELICOPTER ONLY) Rule (5) (f) Certification Minimum EMT At Least Two (2) Years of Emergency Medical or Emergency Communications Experience Initial and Recurrent Training NAACS Certified (Within 12 Months) Scheduling (No more than 16 Hrs in a 24 Hr period) TELECOMMUNICATIONS (HELICOPTER ONLY) Rule (7) EMS EMS Supplemental Telephone No.: ( ) Direct Telephone No.: ( ) Recording Equipment for Telephone and Radio with Instant Recall DEFICIENCIES List all Deficiencies Sited: Audit findings were presented to the Ambulance Service Director on Plan of correction due by: Plan of corrections received on: PH-4243 (7/2014) Page 4 of 5 RDA

05 (5) (f) Certification Minimum EMT At Least Two (2) Years of Emergency Medical or Emergency Communications Experience Initial and Recurrent Training NAACS Certified (Within 12 Months) Scheduling

5 Acceptable Deficient Agency Representative or Director Signature Regional Consultant Signature PH-4243 (7/2014) Page 5 of 5 RDA

RN HELICOPTER. We have fulltime, part-time and casual positions available.

RN HELICOPTER. We have fulltime, part-time and casual positions available. RN HELICOPTER Life Link III s helicopter service provides on-scene emergency response and inter-facility transport. Our helicopters are equipped to handle any type of critically ill or injured patient.