Ohio Admin. Code 4766-4-02 - Application for initial or renewal licensure
[Comment: For dates and availability
of material incorporated by reference in this chapter of the Administrative
Code, see rule
4766-4-18
of the Administrative Code.]
(A)) A
An MTO applying for
initial licensure shall file with the board an
"Application for Ambulance or Mobile Intensive Care License" form in the
English language, and shall submit the completed application to the
board
submit to the board a completed MoICU
application, in the English language, using the MTLS online system :
(1) Accompanied by the appropriate fees as
set forth in rule
4766-4-03 of the
Administrative Code and;
(2) With
all required supporting documentation as set forth in this rule that must be
received by the board.
(B)
A
An MTO applying for renewal of a license shall
file with the board a "Renewal Application for
Ambulance or Mobile Intensive Care License" form in the English language, and
shall submit the completed application to the board
submit to the board a completed renewal application, in the
English language, using the MTLS online system :
(1) Accompanied by the appropriate fees as
set forth in rule
4766-4-03 of the
Administrative Code and;
(2) With
all required supporting documentation as set forth in this rule that must be
received by the board prior to the expiration date of the license.
(C) In addition to the
requirements set forth in section
4766.04
of the Revised Code, for each application the MTO applicant shall provide and
maintain documentation of:
(1) The name of
service, organizational structure and address of applicant to include as
follows:
(a) Name;
(b) Identification of organizational
structure as a corporation (whether for profit or not-for-profit); limited
liability company; partnership; limited liability partnership; government unit;
or sole proprietor (individual human);
(c) Tax identification (tax ID) number or
employer identification number (EIN);
(d) All other names under which applicant
plans to operate while using the same tax ID or EIN number. Business
organizations with different tax ID or EIN numbers cannot operate under the
same license;
(e) Copies of all
trade name registrations and fictitious name registrations for all other names
under which applicant plans to operate on file with the Ohio secretary of
state;
(f) Address of physical
location of applicant's headquarters (no post office box);
(g) Mailing address of applicant;
(2) All medicare provider
numbers;
(3) All medicaid provider
numbers;
(4) Highest level of
service to be provided;
(5) Service
areas including county and state;
(6) A list of the names of all officers,
directors, and/or owners of the MTO;
(7) The name, contact information, and state
of Ohio medical license number of the service's medical director;
(8) For each satellite base, the MTO shall
provide the physical address, city, county, state, and zip code;
(9) The name of the primary contact
person(s), business or administrative office telephone number, e-mail address,
and if applicable, office fax number;
(10) Year of manufacture, make, model,
vehicle identification number, odometer reading, and license plate number
(renewal only) of each MoICU or non-transport vehicle to be
permitted;
(11) A color photograph
of the side of applicant's vehicle displaying color scheme, insignia, monogram,
or other distinguishing characteristic. If multiple color schemes, insignias,
monograms, or other distinguishing characteristics are used, a color photograph
of each shall accompany application.
(a) Color
photographs shall be submitted to the division:
(i) With all initial
"Application for Ambulance or Mobile Intensive Care
License" forms
MoICU applications ;
and
(ii) Within thirty days of the
date a change is made to the vehicle's color scheme, insignia, monogram, or
other distinguishing characteristics.
(b) Digital photographs are
preferred.
(12) A
current and valid certificate of liability insurance in the name of the
applicant, listing the board as a certificate holder with a thirty day
cancellation notice as specified in section
4766.06
of the Revised Code:
(a) The actual name on
the license application shall appear on the certificate of liability
insurance;
(b) Each permitted
vehicle with vehicle identification number (VIN) shall be listed on the
certificate of liability insurance.
(D) An application that is not completed in
the manner as specified on the application or does not include all required
documentation shall be deemed incomplete.
(E) An application deemed incomplete shall
not be considered and may be returned with the notation to the applicant
indicating the reason the application is incomplete.
(F) Failure to provide the required documents
within thirty days of the date the initial "Application for Ambulance or Mobile Intensive Care License"
form
application is received by the
division may result in the application being deemed incomplete.
(G)
A
An MTO shall submit a completed
"Renewal Application for Ambulance or Mobile
Intensive Care License" form
renewal
application , appropriate fees, and supporting documentation to the board
prior to the expiration of the MTO's license in order to be considered
timely.
(H)
The board shall issue a certificate of licensure to the MTOs
that meet the criteria to provide MoICU level of service.
The certificate of licensure issued by the board shall
indicate the highest level of service that the MTO is authorized to
provide.
(I) No applicant or licensed MTO shall submit
false, misleading, or deceptive information in order to obtain a license or
permit.
(J) A license is not
transferable.
Notes
Promulgated Under: 119.03
Statutory Authority: 4766.03
Rule Amplifies: 4766.03, 4766.04, 4766.07
Prior Effective Dates: 04/16/2012, 08/01/2017
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