; EMERGENCY ANDOR ALS AMBULANCE PERMIT APPLICATION PROCESS
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EMERGENCY ANDOR ALS AMBULANCE PERMIT APPLICATION PROCESS

VIEWS: 8 PAGES: 4

  • pg 1
									          EMERGENCY AND/OR ALS AMBULANCE PERMIT
                  APPLICATION PROCESS

 PROCESS                          Provide the Following: A statement of facts showing the experience of the applicant in the
 4001                             operation of an emergency ambulance and/or advanced life support ambulance service
                                  and that the applicant is qualified to render efficient 24-hour emergency ambulance and/or
                                  advanced life support ambulance service.
 Area Description                 Provide a narrative description of the proposed primary emergency ambulance and/or
 4001.a                           advanced life support operations, including but not limited to:
                                  #        Geographic area to be served
                                  #        Level of service
                                  #        Staffing patterns
 Required Equipment               A statement that the applicant owns or has under its control, in good mechanical condition,
 4001.b                           required equipment, to adequately conduct an emergency ambulance and/or advanced life
                                  support ambulance service meeting the requirements established by the California Vehicle
                                  Code and the Sonoma County and/or Mendocino County Emergency Medical Response
                                  Ordinance and EMS policies and procedures.
 Required Vehicles                A statement that the applicant owns or has access to suitable and safe facilities for
 4001.c                           maintaining ambulance(s) in a clean and sanitary condition, and a description of the
                                  facilities.
 Schedule of Rates                A schedule of rates (including any special rates) to be charged for emergency ambulance
 4001.d                           and/or ALS service.
 Conformation to all Provisions   An affirmation that each permitted ambulance and its appurtenances conform to all
 4001.e                           applicable provisions of the California Vehicle Code, the California Administrative Code,
                                  the Sonoma and/or Mendocino County Emergency Medical Ordinance, Coastal Valleys
                                  EMS Agency Ambulance Inventory for ALS, LALS & BLS ambulances and EMS policies
                                  and procedures, and any other applicable State and/or County directives.




Continued on next page                                                                                           R & T Page 12
                         AMBULANCE PERMIT APPLICATION PROCESS CONTINUED

 Program Requirements          Describe how each of the following program requirements will be met:
 4001.f                        #       Ambulances must meet Title 13 requirements as established in California
                                       Administrative Code Sections 1100, et seq.
                               #       Non-transporting vehicles must be equipped and meet applicable laws and
                                       regulations as emergency vehicles.
                               #       A signed statement that all units in the ALS/LALS program are equipped
                                       according to the Coastal Valleys EMS Agency minimum equipment list for
                                       ambulances.
                               #       ALS/LALS units are required to secure and carry required advanced equipment
                                       and supplies.
                               #       ALS services must appoint an Paramedic to serve as liaison to the base hospital.
                               #       LALS services must appoint an EMT-II to serve as liaison to the base hospital.
                               #       ALS/LALS personnel must participate in audit, review and critique of calls and in
                                       continuing education meeting Coastal Valleys EMS Agency and the State of
                                       California standards and requirements.
                               #       ALS/LALS services must hire sufficient persons eligible for the Coastal Valleys
                                       EMS Agency certification to provide 24-hour coverage. State coverage patterns.
 STATEMENTS                    Provide a positive statement accepting each of the following conditions:
 4001.1
 Maintenance of Level of       Applicant does not foresee any reduction from level of service, vehicles, staff or capabilities
 Service                       in any area covered by this application.
 4001.1a
 Employee Orientation          All employees will be adequately oriented to the emergency ambulance and/or advanced
 4001.1b                       life support program and will be encouraged to cooperate with the program.
 Licensed/Accredited           Only licensed and accredited personnel will be allowed to perform advanced procedures.
 Personnel
 4001.1c
 Recordkeeping                 Service will cooperate with the Coastal Valleys Emergency Medical Services Agency in the
 4001.1d                       collection and analysis of patient care and other data necessary to an on-going evaluation
                               of emergency ambulance and advanced life support operations. Necessary records and
                               other information will be provided to the EMS Medical Director (or designee) to allow
                               assessment of emergency ambulance and ALS services. Appropriate confidentiality will be
                               maintained.
 Protocols                     Service agrees that in the operation of an emergency ambulance or advanced life support
 4001.1e                       unit, it will follow all Coastal Valleys Emergency Medical Services Agency protocols,
                               policies and procedures.
 Decertification               Service recognizes the right of the EMS Medical Director and/or the State EMS Authority to
 4001.1f                       suspend or revoke the license of ALS personnel and agrees that persons so suspended or
                               delicensed will not be allowed to operate or function on an ambulance or other advanced
                               life support unit.


Continued on next page                                                                                          R & T Page 13
                         AMBULANCE PERMIT APPLICATION PROCESS CONTINUED

 Records                       Services agrees to complete such reporting mechanisms as required by the County.
 4001.1g
 Replacement of Medications    Service agrees that it will not charge for drugs, medications, solutions or supplies used in
 4001.1h                       any medical emergency when such materials are replaced by a hospital.
 Employment of Personnel       A statement that the applicant employs sufficient certified/licensed personnel, adequately
 4001.1i                       trained and accredited in Coastal Valleys Region to deliver emergency medical services of
                               good quality at all times in the applicant's proposed primary service area.
 Participation in County       A statement that the applicant shall participate in Coastal Valleys Region's Quality
 Quality Improvement Program   Improvement program as outlined in the policies and procedures section of the EMS
 4001.1j                       Policies and Procedures Manual.
 Exclusive Operating Area      A statement that the applicant agrees not to provide emergency ambulance and/or
 4001.1k                       advance life support ambulance services within any exclusive operating areas without
                               specific written permission of the EMS agency, and that the permit holder understands and
                               agrees that if the permit holder does provide such services without specific written
                               permission, it is grounds to revoke their permit.
 Fees                          A statement that the applicant shall pay all appropriate fees as determined by the Sonoma
 4001.1l                       and /or Mendocino County Board of Supervisors. This includes but is not limited to EMS
                               dispatch fees.
 Corporation                   If applicant is a corporation, a joint venture or a partnership or limited partnership, provide
 4001.1m                       the names and permanent addresses of all partners or corporate officers and their
                               percentage of participation the business.
 ATTACHMENTS TO PERMIT         Provide a copy of the following:
 4001.2
 CHP License                   A photocopy of the license issued by the Commissioner of the California Highway Patrol (in
 4001.2a                       accordance with Section 2501, California Vehicle Code and Title 13, California
                               Administrative Code).
 Vehicle List                  A list (to be amended as required during the year for any changed, substituted, loaned or
 4001.2b                       leased vehicles) giving a complete description of each ambulance vehicle operated by the
                               applicant including, but not limited to:
                               #          year of manufacture;
                               #          name of manufacturer of chassis;
                               #          name of manufacturer of patient compartment;
                               #          patient capacity;
                               #          total mileage as of date of application;
                               #          complete inventory of medical and rescue supplies and equipment.
 CHP Ambulance Inspection      A copy of the most recent Ambulance Inspection Report issued by the California Highway
 Forms                         Patrol for each vehicle and a copy of the vehicle certificate issued by the CHP.
 4001.2c


Continued on next page                                                                                           R & T Page 14
                         AMBULANCE PERMIT APPLICATION PROCESS CONTINUED

 Personnel List                A list (to be amended as required during the year for any personnel changes) listing the
 4001.2d                       following information of each ambulance employee:
                               #          name;
                               #          mailing address;
                               #          level of training;
                               #          date of expiration of certification/license.
                                          If not certified in Coastal Valleys Region (for EMT-I only), attach a copy
                                          of California certification.
 STATEMENT OF                  A statement signed by the applicant that as a condition of the County issuing a permit,
 INDEMNIFICATION               applicant agrees to appear and defend all actions against the County arising out of the
 4001.3                        exercise of said permit and shall indemnify and save the County, its' officers, employees
                               and agents harmless and from all claims, demands, actions or causes of action of every
                               kind and description resulting directly or indirectly arising out of, or in any way connected
                               with, the exercise of the permit, shall accompany the permit application.




DATE:             April 2000
REVIEW:           June 2002


                                                                                                                R & T Page 15

								
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