Form MO580-2315 "Air Ambulance Service Review Criteria Check Sheet" - Missouri

What Is Form MO580-2315?

This is a legal form that was released by the Missouri Department of Health and Senior Services - a government authority operating within Missouri. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2007;
  • The latest edition provided by the Missouri Department of Health and Senior Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form MO580-2315 by clicking the link below or browse more documents and templates provided by the Missouri Department of Health and Senior Services.

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Download Form MO580-2315 "Air Ambulance Service Review Criteria Check Sheet" - Missouri

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MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
BUREAU OF EMERGENCY MEDICAL SERVICES
AIR AMBULANCE SERVICE REVIEW CRITERIA CHECK SHEET
NAME OF AIR AMBULANCE SERVICE
LOCATION
DATE
(1) GENERAL REQUIREMENTS FOR AIR AMBULANCE SERVICE LICENSURE
1. Availability of Service (24-hour operation)
MET NOT MET
COMMENTS
Meets needs of service area
2. Insurance – Public Liability Coverage for air ambulance services which transport
patients
MET NOT MET
shall meet or exceed:
$250,000 for bodily injury to, or death of, one person
$500,000 for bodily injury to, or death of, all persons injured or killed in any one
accident, subject to a minimum of $250,000 per person; and
$100,000 for loss or damage to property of others in one accident excluding cargo
3. Staffing patterns
MET NOT MET
(a) Aviation Crew
(b) Medical Crew
(c) Communications Specialist
4. Medical Director qualifications/credentials
MET NOT MET
5. Communications Capability
MET NOT MET
(a) Voice communications
(b) ELT
(2) OPERATIONAL POLICIES AND PROCEDURES
MET NOT MET
COMMENTS
1. Safety program including infection control program
2. Air ambulance operation procedures
3. Communications procedures
4. Standards for clinical care (medical protocols) (standing order authorization)
5. Aircraft and equipment maintenance procedures
6. Controlled substance security and record keeping
7. Disaster/multiple casualty protocols
8. Quality Improvement program (including problem identification and resolution)
9. Nondiscrimination policy regarding treatment or transportation of emergency patients
10. Documentation of ambulance response times
11. Medical Control Plan - Transfer of care between agencies
12. Visual Flight Rule (Rotary Wing Only) Authorized to conduct helicopter air
ambulance operations in accordance with FAR Part 135. See operational stds.
(3) RECORDS AND FORMS
1. Ambulance run report
MET NOT MET
COMMENTS
2. Air ambulance service license (excluding initial licensure)
3. Medical Director protocol and policy authorization
4. Aircraft maintenance records
5. FAA Part 135 Certificate
6. Equipment maintenance records
7. Records required by other regulatory agencies
(4) PATIENT CARE REVIEW
MET NOT MET
REMARKS
SIGNATURE OF BUREAU OF EMERGENCY MEDICAL SERVICES REPRESENTATIVE
DATE
SIGNATURE OF AGENCY REPRESENTATIVE
DATE
MO 580-2315 (R 08/07)
MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
BUREAU OF EMERGENCY MEDICAL SERVICES
AIR AMBULANCE SERVICE REVIEW CRITERIA CHECK SHEET
NAME OF AIR AMBULANCE SERVICE
LOCATION
DATE
(1) GENERAL REQUIREMENTS FOR AIR AMBULANCE SERVICE LICENSURE
1. Availability of Service (24-hour operation)
MET NOT MET
COMMENTS
Meets needs of service area
2. Insurance – Public Liability Coverage for air ambulance services which transport
patients
MET NOT MET
shall meet or exceed:
$250,000 for bodily injury to, or death of, one person
$500,000 for bodily injury to, or death of, all persons injured or killed in any one
accident, subject to a minimum of $250,000 per person; and
$100,000 for loss or damage to property of others in one accident excluding cargo
3. Staffing patterns
MET NOT MET
(a) Aviation Crew
(b) Medical Crew
(c) Communications Specialist
4. Medical Director qualifications/credentials
MET NOT MET
5. Communications Capability
MET NOT MET
(a) Voice communications
(b) ELT
(2) OPERATIONAL POLICIES AND PROCEDURES
MET NOT MET
COMMENTS
1. Safety program including infection control program
2. Air ambulance operation procedures
3. Communications procedures
4. Standards for clinical care (medical protocols) (standing order authorization)
5. Aircraft and equipment maintenance procedures
6. Controlled substance security and record keeping
7. Disaster/multiple casualty protocols
8. Quality Improvement program (including problem identification and resolution)
9. Nondiscrimination policy regarding treatment or transportation of emergency patients
10. Documentation of ambulance response times
11. Medical Control Plan - Transfer of care between agencies
12. Visual Flight Rule (Rotary Wing Only) Authorized to conduct helicopter air
ambulance operations in accordance with FAR Part 135. See operational stds.
(3) RECORDS AND FORMS
1. Ambulance run report
MET NOT MET
COMMENTS
2. Air ambulance service license (excluding initial licensure)
3. Medical Director protocol and policy authorization
4. Aircraft maintenance records
5. FAA Part 135 Certificate
6. Equipment maintenance records
7. Records required by other regulatory agencies
(4) PATIENT CARE REVIEW
MET NOT MET
REMARKS
SIGNATURE OF BUREAU OF EMERGENCY MEDICAL SERVICES REPRESENTATIVE
DATE
SIGNATURE OF AGENCY REPRESENTATIVE
DATE
MO 580-2315 (R 08/07)