Application for an Ambulance Service License
(1)Any person who furnishes, operates, conducts, maintains, advertises, engages in, proposes to engage in, or professes to engage in the provision of ambulance service must be licensed by the Authority and comply with ORS chapter 682; OAR chapter 333, division 255 and these rules before offering such service to the public.
(2)An applicant for an ambulance service license must:
(a)Possess at least one ambulance, facilities, equipment, and a communications system meeting the requirements of these rules and OAR chapter 333, division 255;
(b)Have adequate staffing that supports the type of service, local call volume and the needs of the area as approved by the Authority; and
(c)Comply with all applicable state and federal regulations if laboratory tests are conducted by the ambulance service.
(3)An application for a license to operate an ambulance service shall be submitted electronically in a manner prescribed by the Authority and shall include, but is not limited to, the following information:
(a)The name and address of the person or public entity owning the ambulance service;
(b)If other than the applicant’s true name, the name under which the applicant is doing business;
(c)A corporation, limited partnership, or limited liability company shall attach to the application:
(A)A written statement from the Oregon Secretary of State’s Corporation Division that the ambulance service is registered in accordance with the requirements of the Secretary of State’s Corporation Division and that the ambulance service is in good standing, has filed required annual reports and has paid all registration fees;
(B)The name of the registered agent of the ambulance service that is on file with the Secretary of State’s Corporation Division; and
(C)All trade names recorded with the Secretary of State’s Corporation Division for the business entity, and if the business entity is a subsidiary, all trade names or names of all other subsidiaries recorded with the Secretary of State’s Corporation Division.
(d)A public agency shall attach to the application documentation from an applicable local city or county agency authorizing operation as an ambulance service;
(e)Documentation clearly defining the organizational structure including responsibility, authority and chain of command for all necessary functions within the organization;
(f)The name of the principal contact person that the ambulance service wants contacted regarding official communications from the Authority, if different than the person identified in subsection (3)(a) of this rule;
(g)The mailing and actual street address of the principal place of business of the ambulance service and the actual street address of all fixed locations where an ambulance is parked when not in operation;
(h)Proof of financial responsibility as specified in ORS 682.105 (Proof of financial responsibility required to obtain license);
(i)Copies of all licenses issued by the Federal Communications Commission (FCC) for the operation of the ambulance service’s communications equipment and radio configuration data as required by OAR 333-250-0290 (Communications and Dispatch) or written authorization from a FCC license holder to use the license holder’s frequencies;
(j)If laboratory tests are conducted that require a Clinical Laboratory Improvement Amendment (CLIA) Certificate or CLIA Certificate of Waiver, a copy of the certificate(s);
(k)A copy of the licensed ambulance service’s Air Carrier Operating Certificate, if the service will be operating an air ambulance;
(l)Copies of all primary modes of advertising used by an ambulance service, including but not limited to, brochures and website addresses;
(m)A copy of the paper PCR or, if collecting an ePCR, the name of the software used to report patient encounter data as described in OAR 333-250-0310 (Patient Care Report), as well as the name, address, and contact person of the vendor and the version of the NEMSIS data dictionary used;
(n)The name of the approved EMS medical director and any designated agent(s) meeting the requirements in OAR 333-250-0300 (EMS Medical Direction);
(o)A roster of all EMS providers, ambulance based clinicians, and qualified drivers specifying who shall either operate an ambulance or attend to patients, or both, along with the following information for each employee and volunteer:
(A)The full legal name;
(B)The employment status as either full-time paid, part-time paid or volunteer;
(C)The level of professional license held; and
(D)License numbers, including EMS provider license numbers, driver and pilot license numbers for those persons operating the ambulance.
(p)A list of all ambulances to be operated by the ambulance service under the ambulance service license along with photos and the information required for an ambulance license pursuant to OAR chapter 333, division 255;
(q)A statement under the penalties of perjury that certifies the following:
(A)There has been no attempt to knowingly and willfully falsify, conceal, or omit a material fact, or make any false, fictitious, incomplete or fraudulent statements or representations, or make or use any false writing or document knowing the same to contain any false, fictitious, or fraudulent statement or entry for the purpose of obtaining or attempting to obtain an ambulance service license to operate in the State of Oregon. Where an applicant relies on documents submitted by employees, volunteers, ambulance based clinicians, agents or EMS medical directors, the applicant has made a reasonable effort to verify the validity of those documents;
(B)The applicant authorizes any persons or entities, including but not limited to hospitals, institutions, organizations, or governmental entities to release to the Authority any information, files, or records requested by the Authority in connection with the processing of an application; and
(C)Upon receiving an ambulance service license, the licensed ambulance service authorizes to release information by insurance companies, physicians, health care facilities (including but not limited to, hospitals, nursing homes, urgent care centers or primary care facilities) to the Authority relating to services provided by the ambulance service to those facilities or to patients being taken from or to those facilities.
(r)The completed application must contain the signature(s) of the person(s) having the lawful responsibility for the overall operation of an ambulance service or the authorized person empowered to sign on behalf of the ambulance service; and
(s)Such other information as the Authority may reasonably require.
(4)If the applicant’s primary ambulance service business office is located in another state, the applicant must:
(a)Meet requirements listed in sections (1) through subsection (3)(s) of this rule; and
(b)Attach copies of current ambulance service and ambulance license(s) for that state to the application.
(5)The completed application to license an ambulance service must be accompanied by a nonrefundable licensing fee in accordance with ORS 682.047 (Issuance of license).
Rule 333-250-0210 — Application for an Ambulance Service License,