Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 25 - DEPARTMENT OF HEALTH SERVICES - EMERGENCY MEDICAL SERVICES › Article 13 - TRAUMA CENTERS AND TRAUMA REGISTRIES › Section R9-25-1303 - Application and Designation Process (A.R.S.Sections 36-2202(A)(4), 36-2209(A)(2), and 36-2225(A)(4))

Current through Register Vol. 30, No. 28, July 12, 2024
A. An owner applying for initial designation
				or to renew designation for a health care institution shall submit to the
				Department an application including:
1. The
				following information, in a Department-provided format:
a. The name, address, and telephone number of
				the health care institution for which the owner is requesting
				designation;
b. The owner's name,
				address, e-mail address, telephone number, and, if available, fax
				number;
c. The name, e-mail
				address, telephone number, and, if available, fax number of the chief
				administrative officer, as defined in A.A.C.
				R9-10-101, for the
				health care institution for which the owner is requesting
				designation;
d. The designation
				Level for which the owner is applying;
e. Whether the owner is requesting
				designation for the health care institution based on:
i. Verification, or
ii. Meeting the applicable standards
				specified in
				R9-25-1308
				and Table 13.1;
f. If
				the owner is requesting designation for the health care institution based on
				verification:
i. The name of the national
				verification organization;
ii. The
				name, telephone number, and e-mail address for a representative of the national
				verification organization;
iii. The
				Level of verification held;
iv. The
				effective date of the verification, and
v. The expiration date of the
				verification;
g. If the
				owner is requesting designation for the health care institution based on the
				health care institution meeting the applicable standards specified in
				R9-25-1308
				and Table 13.1:
i. Whether:
(1) A national verification organization has
				assessed the health care institution, or
(2) The Department will be assessing the
				health care institution;
ii. If a national verification organization
				has assessed the health care institution:
(1)
				The name of the national verification organization;
(2) The name, telephone number, and e-mail
				address for a representative of the national verification organization;
				and
(3) The date the national
				verification organization assessed the health care institution; and
iii. If the Department will be
				assessing the health care institution, the date the health care institution
				will be ready for the Department to assess the health care
				institution;
h. Unless
				the owner is an administrative unit of the U.S. government or a sovereign
				tribal nation, the license number, issued by the Department, for the health
				care institution for which designation is being requested;
i. The name, e-mail address, telephone
				number, and, if available, fax number of the health care institution's trauma
				program manager;
j. Whether the
				health care institution's trauma registry will be located at the health care
				institution or be part of a centralized trauma registry;
k. The name, e-mail address, telephone
				number, and, if available, fax number of the health care institution's trauma
				registrar;
l. If applying for
				designation as a Level IV trauma center, whether the health care institution
				plans to submit, in addition to the information required in R9-25-1309(A), the
				information specified in
				R9-25-1309(B);
m. If not already submitting trauma registry
				information to the Department, the time period for which the health care
				institution plans to begin submitting trauma registry information;
n. Except for a health care institution
				applying for designation as a Level IV trauma center, the name, e-mail address,
				telephone number, and, if available, fax number of the health care
				institution's trauma medical director;
o. The name, title, address, and telephone
				number of the owner's statutory agent or the individual designated by the owner
				to accept service of process and subpoenas;
p. Attestation that:
i. The owner will comply with all applicable
				requirements in A.R.S. Title 36, Chapter 21.1 and this Article; and
ii. The information and documents provided as
				part of the application are accurate and complete; and
q. The dated signature of the applicable
				individual according to R9-25-102;