Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 25 - DEPARTMENT OF HEALTH SERVICES - EMERGENCY MEDICAL SERVICES › Article 9 - GROUND AMBULANCE CERTIFICATE OF NECESSITY › Section 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)

Current through Register Vol. 30, No. 28, July 12, 2024
A. An applicant for
				an initial certificate of necessity shall submit to the Department an
				application packet that includes:
1. The
				following information in a Department-provided format:
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;
e. The name, title,
				address, e-mail address, and telephone number of the following:
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;
f. The name, address,
				email address, and telephone number of the person providing dispatch for the
				ground ambulance service;
g. The address, hours of
				operation, and, if available, telephone number of each suboperation station
				located within the proposed service area;
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;
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;
k. A
				description of the communication equipment to be used in each ground ambulance
				vehicle and suboperation station;
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;
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;
n. The number of
				ambulance attendants and the type of licensure, certification, or registration
				for each attendant;
o. The proposed hours of
				operation for the ground ambulance service;
p. The type of
				service;
q. The level of
				service;
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;
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;
u. Attestation that any
				information or documents submitted to the Department are true and correct;
				and
v. The signature of the
				individual acting for the applicant according to
				R9-25-102 and the date
				signed;