Ohio Admin. Code 4766-5-02 - Application for initial or renewal licensure
(A)
An AMSO applying for initial licensure shall file with
the board an "Application for Air Medical License" form in the English language
and shall submit the completed application to the board:
(1)
Accompanied by
the appropriate fees as set forth in rule
4766-5-03 of the
Administrative Code; and
(2)
With all required supporting documentation as set forth
in this rule.
(B)
An AMSO applying for renewal of a license shall file
with the board a "Renewal Application for Air Medical License" form in the
English language, and shall submit the completed application to the
board:
(1)
Accompanied by the appropriate fees as set forth in rule
4766-5-03 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 AMSO applicant shall provide:
(1)
The name of the
service, organizational structure, and address of AMSO 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) shall be located in Ohio or a state
contiguous to Ohio;
(g)
Mailing address of applicant.
(2)
All
medicare provider numbers;
(3)
All medicaid
provider numbers;
(4)
Ohio service areas including county;
(5)
A list of the
names of all officers, directors, and/or owners of the AMSO;
(6)
The name, contact
information, and state of Ohio medical license number of the service's medical
director;
(7)
For each satellite base, the AMSO shall provide the
physical address, city, county, state, and zip code;
(8)
The name of the
primary contact person(s), business or administrative office telephone number,
e-mail address, and if applicable, office fax number;
(9)
Year of
manufacture, make, model, tail number, and aircraft hours on
airframe;
(10)
A color photograph of the side of the applicant's
aircraft 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 Air Medical License"
forms; and
(ii)
Within thirty days of the date a change is made to the
aircraft's color scheme, insignia, monogram, or other distinguishing
characteristics.
(b)
Digital
photographs are preferred.
(11)
A current
certificate of liability insurance in the name of the applicant, listing state
board of emergency medical, fire, and transportation services 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 aircraft with year, make, model, and
tail number 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 Air Medical License" form is
received by the division may result in the application being deemed
incomplete.
(G)
An AMSO shall submit a completed "Renewal Application
for Air Medical License" form, appropriate fees, and supporting documentation
to the board prior to the expiration of the AMSO's license in order to be
considered timely.
(H)
No applicant or licensed AMSO shall submit false
information in order to obtain a license or permit.
(I)
A license is only
valid for the AMSO for which it is issued and is not transferable.
Replaces: 4766-5-02
Notes
Promulgated Under: 119.03
Statutory Authority: 4766.03
Rule Amplifies: 4766.03, 4766.04, 4766.06, 4766.07
Prior Effective Dates: 07/02/2009, 09/26/2014
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