HomeMy WebLinkAboutcert-of-operation-application-013017-8-12-2020
Application for Non-Emergency Ambulance Service
Certificate of Operation
Alameda County Emergency Medical Services
Initial Application Renewal Application Information Update
Applicant’s Name:
Company name:
Address:
Street City
State Zip
Phone: ( ) - Fax: ( ) - email:
registered owner partner officer director controlling share holder
(Provide the above information for all additional applicants on Attachment A and attach to this application)
Service level requested: BLS CCT (CCT-P requires a separate process)
If yes, what type of service: BLS CCT ALS
Have you ever provided ambulance service in
Company name:
Alameda County? Yes No
For how long:
Do you provide ambulance service outside Alameda If yes, what type of service: BLS CCT ALS
County? Yes No Company name:
List counties: ______________________________ For how long:
Describe your education, training and experience in the care and transportation of patient:
(attach addition pages as needed)
The number, type, and frequency of radios:
Please answer the following:
For more information see the Alameda County ambulance ordinance and/or EMS policy manuals
located on the EMS agency website (acphd.org/ems)
1. Do you own or have under your control, in good mechanical condition, required
equipment to consistently provide quality ambulance service in the area for which
Yes No
you are applying, and that you own or have access to suitable facilities for
maintaining equipment in a clean and sanitary condition?
2. Will you comply with the County’s staffing, and equipment and supply specifications
Yes No
policies regarding equipment carried in each ambulance, including AEDs?
3. Do you or will you have sufficient personnel adequately trained and available to
deliver ambulance service of good quality at all times, including copies of
Yes No
certifications/licenses?
By signing below, the applicant agrees to abide by the regulations of the California Vehicle Code and the
California Code or Regulations, Title 13, Motor Vehicles, and understands and will comply with Alameda
County’s policies, ambulance ordinance, fees, and ambulance inspection process.
________________________________________________ __________________
Signature Date
Alameda County Ambulance Service Application - Revised: August 12, 2020
Required attachments:
Please assemble the application components below into a binder with the attachments under lettered tabs.
Items with an asterisk “*” may be submitted on a CD. Please adhere to this lettering scheme and if
submitting material electronically, so indicate on a page under that tab.
Attached?
Yes
A. Certificate of Operation application.
Yes
B. Additional applicants form (if there are no additional applicants, write “None”
on the form).
C. A statement or resume specifying the education, training, and experience of
the applicant in the care and transportation of patients.
Yes
D. A statement of the legal history of all applicants, including criminal and civil
convictions, pending criminal or civil proceedings, and whether the applicant
has ever had any licenses revoked and/or been investigated by any
governmental agency, and disclosure of the nature of the investigation.
Yes
E. A copy of a current CHP Emergency Ambulance Service License (CHP 360A).
Yes
F. An assets and liabilities statement or a letter prepared by a certified public
*
accountant showing that the applicant has adequate financial health, based
on liquidity, profitability, and sustainability, to maintain ambulance service
operations.
Yes
G. A copy of the business license for the city in which the applicant is doing
business.
Yes
H. A status report of all ambulances permitted in the previous two years that will
not be permitted with this application (renewal application only).
Yes
I. Vehicle information for all ambulances, including proof of current Department
of Motor Vehicle registration, and proof of a California Highway Patrol
Ambulance Inspection Report, Special Vehicle Identification Certificate/Permit
(CHP-301) and proof of insurance. Please label all pages with the appropriate
unit numbers.
Yes
J. A description and photo/image of the company’s logo and color scheme to be
used.
Yes
K. A description of the company's program for maintenance of the vehicles.
Yes
L. The company locations from which ambulances will be deployed, noting the
hours of operation and phone numbers, and the number of ambulances
deployed on each shift; and a 24-hour availability number for supervisory or
management contact.
Yes
M. A description of service charges and rates as specified in section 6.114.310 of
the ordinance. All service charges and rates must be defined in sufficient
detail so as to be understandable to the public.
Yes
N. Evidence of insurance coverage compliance under section 6.114.130 of the
*
ordinance.
Yes
O. A Certificate of Consent to Self-Insure issued by the California State Director
of Industrial Relations, or a Certificate of Workman’s Compensation
Insurance.
Yes
P. A description of the company’s training and orientation programs for EMTs,
*
and/or CCT-Paramedics, and/or CCT-RNs, including an EVOC course.
Yes
Q. A description of your Dispatcher Training program as identified in 6.114.280
*
Yes
R. A Quality Management program and description of quality assurance activities
*
as specified in section 6.114.410.
Yes *
S. A Disaster Response Plan that includes a personnel call-back plan for
Alameda County Ambulance Service Application - Revised: August 12, 2020
disasters and mass casualty incidents as specified in section 6.114.460.
Yes
T. If applying for a Critical Care Transport (CCT) Certificate of Operation, copies
*
of all paperwork for interfacility transport as identified in the Alameda County
CCT and Administrative polices.
U. The application fees (payable to Alameda County EMS). Renewal applications
received less than 30 days before the expiration of the Certificate of
Operation shall incur a 20% penalty of all fees due.
Yes
a. Certificate of operation fee ($3000.00 biennial).
b. In a separate payment, the ambulance permit fee (for each ambulance Yes
permit requested ($250.00 fee per ambulance, biennial). This fee will
be returned if the applicant does not meet the basic requirements of
6.114.080 (C).
c. Biennial is defined as every other year.
Yes
d. The 20% late fee if it applies.
Deliver or mail the completed package, in a tabbed binder, to:
Alameda County EMS
EMS Coordinator - Ambulance Ordinance
nd
1000 San Leandro Blvd, 2 floor
San Leandro, CA 94577
** Documents submitted electronically may be acceptable. Please check with the
EMS coordinator assigned.
Alameda County Ambulance Service Application - Revised: August 12, 2020
Attachment A
Additional Applicant Information
No additional applicants
Applicant name:
Address:
Street City
Sate zip
Phone: ( ) - Fax: ( ) - email:
registered owner partner officer director controlling share holder
(provide the above information for all applicants and attach to this application as “Attachment A”)
Applicant name:
Address:
Street City
Sate zip
Phone: ( ) - Fax: ( ) - email:
registered owner partner officer director controlling share holder
(provide the above information for all applicants and attach to this application as “Attachment A”)
Applicant name:
Address:
Street City
Sate zip
Phone: ( ) - Fax: ( ) - email:
registered owner partner officer director controlling share holder
(provide the above information for all applicants and attach to this application as “Attachment A”)
Applicant name:
Address:
Street City
Sate zip
Phone: ( ) - Fax: ( ) - email:
registered owner partner officer director controlling share holder
(provide the above information for all applicants and attach to this application as “Attachment A”)
Add additional pages as needed
Alameda County Ambulance Service Application - Revised: August 12, 2020
Attachment F
Vehicle Information
Old
Unit # Make Model Year VIN # License # Cell Phone #
ALCO
Permit #
( ) -
( ) -
( ) -
( ) -
( ) -
( ) -
( ) -
( ) -
( ) -
( ) -
( ) -
( ) -
( ) -
( ) -
( ) -
( ) -
( ) -
( ) -
( ) -
( ) -
( ) -
( ) -
( ) -
Attach to this application proof of current Department of Motor Vehicle registration and proof of California Highway Patrol Ambulance
Inspection Report and Special Vehicle Identification Certificate/Permit - Add additional pages as needed
Alameda County Ambulance Service Application - Revised: August 12, 2020