Arizona Administrative Code
Title 9 - HEALTH SERVICES
Chapter 25 - DEPARTMENT OF HEALTH SERVICES - EMERGENCY MEDICAL SERVICES
Article 2 - MEDICAL DIRECTION; ALS BASE HOSPITAL CERTIFICATION
Section R9-25-204 - Application Requirements for ALS Base Hospital Certification (Authorized by A.R.S. sections 36-2201, 36-2202(A)(3) and (A)(4), and 36-2204(5))
Universal Citation: AZ Admin Code R 9-25-204
Current through Register Vol. 31, No. 12, March 21, 2025
A. An applicant for ALS base hospital certification shall submit to the Department an application, including:
1. The following information in a
Department-provided format:
a. The
applicant's name, address, and telephone number;
b. The name, email address, and telephone
number of the applicant's chief administrative officer;
c. The name, email address, and telephone
number of the applicant's chief administrative officer's designee if the chief
administrative officer will not be the liaison between the ALS base hospital
and the Department;
d. Whether the
applicant is applying for certification of a:
i. General hospital licensed under 9 A.A.C.
10, Article 2;
ii. Special hospital
licensed under 9 A.A.C. 10, Article 2, that provides surgical services and
emergency services only to children; or
iii. Facility operating as a federal or
tribal hospital;
e. The
name of each emergency medical services provider or ambulance service for which
the applicant has a proposed written agreement described in A.R.S. §
36-2201(4) to provide administrative medical direction
or on-line medical direction;
f.
The name, address, email address, and telephone number of each administrative
medical director;
g. The name of
each physician providing on-line medical direction;
h. Attestation that the applicant meets the
requirements in
R9-25-202(D);
i. Attestation that the applicant will comply
with all requirements in A.R.S. Title 36, Chapter 21.1 and this
Chapter;
j. Attestation that all
information required as part of the application has been submitted and is true
and accurate; and
k. The signature
or electronic signature of the applicant's chief administrative officer or the
chief administrative officer's designated representative and date of signature
or electronic signature;
2. A copy of the applicant's current hospital
license issued under 9 A.A.C. 10, Article 2, if applicable; and
3. A copy of each executed written agreement
described in A.R.S. §
36-2201(4),
including all attachments and exhibits.
B. The Department shall approve or deny an application under this Section according to Article 12 of this Chapter.
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