Current through Register Vol. 49, No. 13, September 23, 2024
Subpart 1.
Specific information required.
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:
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 adviser or medical director of
the service and the base hospital or affiliated medical facility, if any, for
the service;
D. the location of the
communications base and a description of the communications equipment on the
licensee's ambulances and at its communications base;
E. 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;
F. the type and identification of
ownership;
G. the type and
identification of the entity responsible for operation, if different from
ownership;
H. backup coverage,
including reserve ambulances owned by applicant, backup services, and copies of
signed mutual aid agreements with neighboring providers;
I. other licensed providers in the primary
service area;
J. a description of
the population to be served;
K.
type of service to be licensed;
L.
actual past and 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 of and credentials of attendants and drivers and names and addresses of
key personnel;
O. a listing and
description of all ambulances to be used by the service if licensed;
P. a description of any proposed new service,
change of base of operation, 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 shall furnish other information that may be needed
by the board to clarify incomplete or ambiguous information presented in the
application.
Subp. 3.
Documentation of information.
Applicants shall retain in their files documentation of all
statements made in applications for licensure.
