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Ohio Administrative Code (Last Updated: January 12, 2021) |
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4766 Ohio Medical Transportation Board |
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Chapter4766-5. Medical Transportation |
4766-5-02. Application for initial or renewal licensure
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[Comment: For dates and availability of material incorporated by reference in this chapter of the Administrative Code, see rule 4766-5-18 of the Administrative Code.]
(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.