Minnesota Administrative Rules

4690.0200 CONTENTS OF APPLICATIONS.

Subpart 1.

Specific information required for new service, primary service area expansion, or change to type of service.

An application for licensure of a new service, expansion of primary service area, or change in type of service provided must be made on a form provided by the director 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.16 and 144E.30, and to provide sufficient information for local and regional reviews prescribed in Minnesota Statutes, section 144E.10:

A.

identification, location, and pertinent telephone numbers for the proposed service and the name of the individual responsible for accuracy of the application;

B.

the addresses of the base of operation and substations;

C.

the names, addresses, and telephone numbers of the medical director of the service and the base hospital or affiliated medical facility, if any, for the service;

D.

the name, location, and telephone number of the primary provider of dispatch services and a description of the communications equipment on the licensee's ambulances;

E.

whether the application is for a new license, expansion of primary service area, or change in type of service provided;

F.

the type and identification of ownership;

G.

the type and identification of the entity responsible for operation of the service, if different from ownership;

H.

copies of signed mutual aid agreements and any staffing agreements with neighboring providers;

I.

other licensed providers in the primary service area;

J.

a description of the population to be served;

K.

the type of service to be licensed;

L.

estimated future utilization of the service;

M.

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;

N.

qualifications of personnel, including number and credentials of attendants and drivers, and contact information of key personnel, including telephone number and email address;

O.

a listing and description of all ambulances to be used by the service if licensed;

P.

a description of any proposed new service, expansion of primary service area, or change in type of service;

Q.

a justification of the need for any proposed new service or modification in service; and

R.

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.

Subp. 2.

Other information required.

Applicants submitting an application under this part shall furnish other information that may be needed by the director to clarify incomplete or ambiguous information presented in the application.

Subp. 3.

Documentation of information.

Applicants submitting an application under this part shall retain in their files documentation of all statements made in applications for licensure.

Subp. 4.

Specific information required for renewal applications.

A.

An application for license renewal must be made on a form provided by the director and must include, at a minimum, the following categories of information:

(1)

identification, location, and pertinent telephone numbers for the service and the name of the individual responsible for accuracy of the application;

(2)

the addresses of the base of operation and substations;

(3)

the names, addresses, and telephone numbers of the medical director of the service and the base hospital or affiliated medical facility, if any, for the service;

(4)

the name, location, and telephone number of the primary provider of ambulance dispatch services and a description of the communications equipment on the licensee's ambulances;

(5)

the type and identification of ownership;

(6)

the type and identification of the entity responsible for operation of the service, if different from ownership;

(7)

copies of signed mutual aid agreements and any staffing agreements with neighboring providers;

(8)

the type of service to be licensed;

(9)

actual past utilization of the service;

(10)

certification as to whether the applicant has completed the most recent cost collection report collected by the director pursuant to Minnesota Statutes, section 62J.49;

(11)

qualifications of personnel, including number and credentials of attendants and drivers, and contact information of key personnel, including telephone number and email address;

(12)

a listing and description of all ambulances to be used by the service; and

(13)

certification that the renewal application does not contain any of the following:

(a)

a proposed new service;

(b)

an expansion of primary service area; or

(c)

a change in type of service.

B.

If the application contains any of the units listed in item A, subitem (13), the licensee must also submit all of the information required under subpart 1.

Statutory Authority:

MS s 144.804; 144E.011; 144E.16

History:

L 1996 c 324 s 6; L 1997 c 199 s 14; 51 SR 469

Published Electronically:

October 29, 2026