"Instructions for the Completion of Oklahoma's Pre-hospital Emergency Medical Response Agency Initial Application Forms" - Oklahoma

Instructions for the Completion of Oklahoma's Pre-hospital Emergency Medical Response Agency Initial Application Forms is a legal document that was released by the Oklahoma State Department of Education - a government authority operating within Oklahoma.

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Download "Instructions for the Completion of Oklahoma's Pre-hospital Emergency Medical Response Agency Initial Application Forms" - Oklahoma

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Oklahoma State Department of Health
Protective Health Services
Emergency Systems/EMS Division
th
1000 N.E. 10
Street
Oklahoma City, OK 73117-1299
Telephone: (405) 271-4027
Fax: (405) 271-4240
INSTRUCTIONS
FOR THE
COMPLETION
OF
OKLAHOMA’S
PRE- HOSPITAL
EMERGENCY MEDICAL RESPONSE AGENCY
INITIAL APPLICATION FORMS
O.A.C. 310:641
1
Effective: September 1, 2016
Oklahoma State Department of Health
Protective Health Services
Emergency Systems/EMS Division
th
1000 N.E. 10
Street
Oklahoma City, OK 73117-1299
Telephone: (405) 271-4027
Fax: (405) 271-4240
INSTRUCTIONS
FOR THE
COMPLETION
OF
OKLAHOMA’S
PRE- HOSPITAL
EMERGENCY MEDICAL RESPONSE AGENCY
INITIAL APPLICATION FORMS
O.A.C. 310:641
1
Effective: September 1, 2016
Oklahoma State Department of Health
Protective Health Services
Emergency Systems/EMS Division
th
1000 N.E. 10
Street
Oklahoma City, OK 73117-1299
Telephone: (405) 271-4027
Fax: (405) 271-4240
APPLICATION: Please type or print all information, except where a signature is required.
Type of Fee
Reg
Fee for Initial Certification
Fee for certification
O.A.C. 310:641-15-2 (h) (11)
$50.00 (non- refundable)
Renewal of certification
310:641-15-6 (a) (2)
$20.00 (non-refundable)
Section 1 – Type of Application
Enter the date of the application.
Enter the application purpose.
When amending the current license, use the OSDH EMRA Amendment form found in the
Forms section of the Emergency Systems website.
Section 2 – Business Information
Enter the name of your agency.
Enter the mailing address of your agency including city, state and zip code.
Enter the physical address of your agency including city, state and zip code.
Enter the records retention address (address of where the agency records will be kept)
including city, state and zip code.
Enter the business telephone number and an emergency telephone number.
Enter the name of the person who will be a point of contact for the Department.
Enter an email that the point of contact will be able to access to receive correspondence
for the Department.
Enter the days and times of the agencies operations. Please include the days and times
that records will be available for an unannounced inspection review.
Additional points of contact may be included with the application
Section 3 – Level of Care (310:641-15-2 (k) (2)
Select the level of care that will be provided.
Emergency Medical Responder
Basic life support
Intermediate life support
Advanced life support
Paramedic life support
Section 4 – Type of Owner (O.A.C. 310:641-15-2 (h) (1) (A) - (B))
Enter the type of ownership for the agency. Essentially, what type of organization will own the
license?
Will an Ambulance Service District (522 District or a Title 19) District own the
license?
Will a Fire Protection District (Title 18 or Title 19 District) own the license?
Will a different type of board or trust own the license?
O.A.C. 310:641
2
Effective: September 1, 2016
Oklahoma State Department of Health
Protective Health Services
Emergency Systems/EMS Division
th
1000 N.E. 10
Street
Oklahoma City, OK 73117-1299
Telephone: (405) 271-4027
Fax: (405) 271-4240
Section 5 – Type of Operation
Enter the type of operation for the agency. For Section 5 and 6 – These are examples of type of
owner and type of operation combinations:
A city (or county) owns the license, and the service is based in the city fire department,
then governmental city (or county) and fire-based would be marked.
A city (or county) owns the license, and the service is based in the police department (or
county sheriff’s office), then governmental city (or county) and law enforcement would be
marked.
A city (or county) owns a hospital, and the service is based in the hospital, then
governmental city (or county) and hospital would be marked.
A city or county owns a hospital, and then appoints a board for the hospital. The city still
owns the hospital.
If a board owns the hospital, then it will be a board or trust that is marked with hospital.
If the license will be owned by an Ambulance Service District (522 District or Title 19) or
a Fire District (Title 18 or Title 19), then mark either Fire Based or other type of
operation.
Third service means the agency is not fire or law enforcement based but is
governmental owned.
Section 6 –Communication Policy (O.A.C. 310:641-15-2 (h) (8) (A and B))
Agency Dispatch
Enter the agency phone number to be used by dispatch to contact by phone.
Enter who will receive the call (i.e. crew members, agency dispatcher).
Other Dispatch
Enter the agency that is providing dispatch to the agency.
Enter the phone number of the agency providing dispatch for the agency.
Radio System
Enter the type of two-way radio communication maintained by the agency
(UHF/VHF/800 MHz
Enter the frequency being used for dispatch if applicable.
(NOTE: The agency must maintain a communication policy that addresses how it receives and
dispatches both emergency and non-emergency calls. The communication plan must be
compliant with Local, State and Federal communication plans. The agency must complete and
submit a statement stating the agency has a communication policy as part of this application.)
Section 7 – Quality Assurance Plan and Protocols (310:641-15-2 (H) (7) (A) – (C))
See Protocol Application Forms
Section 8 – Additional Documentation
These additional documents that are to be submitted with the application.
Applications without these documents are incomplete.
Contracts for equipment and services are to be submitted, if applicable.
O.A.C. 310:641
3
Effective: September 1, 2016
Oklahoma State Department of Health
Protective Health Services
Emergency Systems/EMS Division
th
1000 N.E. 10
Street
Oklahoma City, OK 73117-1299
Telephone: (405) 271-4027
Fax: (405) 271-4240
For each unit the applicant owns, complete a vehicle checklist and submit with the
application
Section 9 – Proposed Level of Service in Proposed Response Area
(O.A.C. 310:641-15-2 (k) (1) – (3)
Enclose a description of the proposed level of service in the response area and include:
1) a map defining the primary emergency response area including base station, substations,
posts, and consistent with local or regional emergency communication plans (e.g. 911 center);
2) a description of the level of care to be provided and describing any variations in care within
the area; and
3) Emergency Medical Response Agency applicants will provide documentation that reflects
compliance with existing sole-source ordinances.
Section 10 – Type of Owner (O.A.C. 310:641-15-2 (h) (1) (A)- (B))
Enter the name of the agency owner (You must also complete and submit the ownership
supplementary form)
A business plan is also required. The plan must include a financial disclosure statement
showing evidence of the ability to sustain the operation for at least one (1) year.
Section 11 – Indirect Ownership (O.A.C. 310:641-15-2 (h) (1) (A)- (B))
List the names and addresses of individuals, organizations or other entities having a direct or
indirect ownership interest(s), separately or in combination, amounting to an ownership interest
of 5% or more in the DISCLOSING ENTITY.
Section 12 – Mortgage (O.A.C. 310:641-15-2 (h) (1) (A) - (B))
List the names and addresses of individual, organizations or other entities having an interest in
the form of the mortgage, or other obligation, secured by disclosing entity (equal to at least 5%
of the assets).
Section 13 – Corporation Officers / Directors (O.A.C. 310:641-15-2 (h) (1) (A) - (B))
If the disclosing entity is a CORPORATION, list the names, titles and addresses of the officers
and directors.
Section 14 – Felony Statement (O.A.C. 310:641-15-7 (a) (1))
Has any owner, principal, officer, or director been convicted of a felony? If yes, please indicate
details on a separate peace of paper. The applicant may also submit court documents detailing
the felony conviction.
Section 15 - EMS District Board (O.A.C. 310:641-15-2 (h) (1) (A) - (B))
If the disclosing entity is a ‘522’ District Board, or received money from a ‘522’ District Board, list
the names, titles and addresses of the officers and directors.
Section 16 – Other Ownership or Controlling Interests
(O.A.C. 310:641-15-2 (h) (1) (A) - (B))
O.A.C. 310:641
4
Effective: September 1, 2016
Oklahoma State Department of Health
Protective Health Services
Emergency Systems/EMS Division
th
1000 N.E. 10
Street
Oklahoma City, OK 73117-1299
Telephone: (405) 271-4027
Fax: (405) 271-4240
If the disclosing entity is an Ambulance District Board established by Title 19, received money
from an Ambulance District Board ( (“522 or “Title 19”), a city, a county , a council, or any entity
list the names, titles, and addresses of the officer, directors, commissioners, council, etc. Give
meeting dates, times and other pertinent information.
Section 17– Owner Signature (O.A.C. 310:641-15-2 (f))
Print the license owner’s name in the space provided.
Print the license owner’s title in the space provided.
Enter the date in the space provided.
The license owner must sign in the space provided.
The signature must be verified by a notary public.
Additional Forms
Personnel Roster – List all personnel for your agency who provide patient care.
Inspection Forms – This form is used by the Department for inspections. Complete the
form to provide us with your ambulance’s information as well as an equipment checklist.
Complete this form for each of your agency’s ambulances. The Record Review checklist
detail records to be maintained at the agency.
Medical Director – See the attached Medical Director Checklist to ensure you are
sending all of the required information.
Approved Procedures List – Part of Protocol Application forms
Substations – Check “yes” if your agency will maintain substations. Complete and
submit the Ambulance Substation form with your application.
Department Application Procedures
After submitting your application, it will be reviewed by Department staff for completeness,
accuracy and legibility. You will be contacted if the package is incomplete or additional
information is required. Once the application is complete, an EMS Administrator will be
assigned to conduct an initial inspection of your files, equipment and facility. Upon receipt of the
EMS Administrator’s inspection report, your EMS Agency Certificate will be mailed to the
address on record. Information regarding your Ground Ambulance application package may be
obtained by calling (405) 271-4027.
O.A.C. 310:641
5
Effective: September 1, 2016
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