An application for license renewal, or for licensure of a new service, expansion of primary service area, change of base of operation, or type of service provided must be made on a form provided by the board and must include, at a minimum, the following categories of information to allow a determination of compliance with the requirements of Minnesota Statutes, sections 144E.001 to 144E.17 and 144E.30 and to provide sufficient information for local and regional reviews prescribed in Minnesota Statutes, section 144E.10:
identification, location, and pertinent telephone numbers for the proposed service and the name of the individual responsible for accuracy of the application;
the addresses of the base of operation and substations;
the names, addresses, and telephone numbers of the medical adviser or medical director of the service and the base hospital or affiliated medical facility, if any, for the service;
the location of the communications base and a description of the communications equipment on the licensee's ambulances and at its communications base;
whether the application is for a new license, license renewal, expansion of primary service area, change of base of operations, or change in type of service provided;
the type and identification of ownership;
the type and identification of the entity responsible for operation, if different from ownership;
backup coverage, including reserve ambulances owned by applicant, backup services, and copies of signed mutual aid agreements with neighboring providers;
other licensed providers in the primary service area;
a description of the population to be served;
type of service to be licensed;
actual past and estimated future utilization of the service;
basic actual or estimated financial data, including actual and in kind revenue or income, actual or projected patient charges, sources of revenue by type, and actual and imputed expenses by category and projected capital costs and operating costs;
qualifications of personnel, including number of and credentials of attendants and drivers and names and addresses of key personnel;
a listing and description of all ambulances to be used by the service if licensed;
a description of any proposed new service, change of base of operation, expansion of primary service area, or change in type of service;
a justification of the need for any proposed new service or modification in service; and
a declaration of the proposed primary service area, including a description of the geographic features of the primary service area that have a direct bearing on the proposed service or modified service.
Applicants shall furnish other information that may be needed by the board to clarify incomplete or ambiguous information presented in the application.
Applicants shall retain in their files documentation of all statements made in applications for licensure.
L 1996 c 324 s 6; L 1997 c 199 s 14
December 12, 2012