Md. Code Regs. 30.09.04.03

Current through Register Vol. 51, No. 22, November 1, 2024

Section 30.09.04.03 - Application for Commercial Ambulance Service License

A. An applicant for a commercial ambulance service license shall submit a completed application to SOCALR on the required form.

B. A completed application shall contain:

(1) The commercial ambulance service's:

(a) Name;

(b) Principal physical business address;

(c) Billing address;

(d) Telephone number;

(e) Facsimile number;

(f) E-mail address;

(g) Principal contact individual's name for official communications from MIEMSS;

(h) Principal contact individual's name for daily operations;

(i) Federal tax identification number; and

(j) Entity type;

(2) For a corporation, limited partnership, or a limited liability company:

(a) A statement that the commercial ambulance service:

(i) Is registered under the Corporations and Associations Article, Annotated Code of Maryland, in good standing,

(ii) Has filed all required annual reports, and

(iii) Has paid all required filing fees to the Maryland Department of Assessments and Taxation; and

(b) The name of the resident agent on file with the Charter Division of the Maryland Department of Assessments and Taxation;

(3) The principal place of business on file with or recognized by the:

(a) Charter Division of the Maryland Department of Assessments and Taxation; or

(b) Central Registration Unit of the Comptroller of the Treasury;

(4) An agreement and representation that the commercial ambulance service:

(a) Is qualified to do business in Maryland; and

(b) Will take all necessary actions to remain qualified while licensed in Maryland;

(5) For an air ambulance service:

(a) If CAMTS accredited, a copy of the current CAMTS accreditation certificate; or

(b) If CAMTS accreditation is pending:

(i) A copy of the FAA operating certificate; and

(ii) Proof of compliance with CAMTS standards;

(6) All trade names under which the commercial ambulance service and any parent or subsidiary does or has ever done business;

(7) The current Maryland Medical Assistance Program provider/vendor numbers issued by the Maryland Department of Health and Mental Hygiene to the commercial ambulance service under its name or any of its trade names;

(8) The CLIA (Clinical Laboratory Improvement Amendment) identification number, if issued;

(9) The street address for each location the commercial ambulance service intends to operate including where:

(a) Ambulances are parked or stored;

(b) Records are kept;

(c) Supplies are stored;

(d) Ambulance crews are quartered; and

(e) Ambulances are dispatched;

(10) The following information about management personnel and owners:

(a) Names;

(b) Addresses;

(c) Telephone numbers; and

(d) Titles;

(11) The following information about each employee who may provide patient care:

(a) Name;

(b) Type of health care certification or license and the identity of the issuer; and

(c) Certification or license number;

(12) A listing of all commercial ambulances to be operated by the service under the service license applied for with the information required for a commercial ambulance license in Regulation .05B(2) of this chapter;

(13) A signed written statement under the penalties of perjury that:

(a) There has been no attempt for the purpose of obtaining or attempting to obtain a license, to knowingly and willfully:

(i) Falsify, conceal, or omit a material fact,

(ii) Make any false, fictitious, incomplete, or fraudulent statements or representations, or

(iii) Make or use any false writing, document, or entry knowing the same to contain any false, fictitious, or fraudulent statement; and

(b) The signer is authorized by the commercial ambulance service identified on the application to sign the application form to execute the sworn statement;

(14) The signatures of:

(a) If a sole proprietorship, the owner;

(b) If a partnership, all general partners;

(c) If a corporation, a duly authorized corporate official accompanied by a certified corporate resolution authorizing the execution; or

(d) If a limited liability company, an authorized individual; and

(15) Any additional information which SOCALR may consider necessary.

C. The applicant shall submit with the application the applicable fees required in Regulation .07 of this chapter together with the documents required in this subtitle.

D. Before accepting any license for which it applied, the commercial ambulance service shall notify SOCALR of any changes to the information previously submitted on the application which occur before the license is granted, regarding:

(1) The commercial ambulances;

(2) Commercial ambulance service personnel; or

(3) Any other material information in the application.

Md. Code Regs. 30.09.04.03

Regulations .03, Eligibility, Application, and License Renewal, adopted effective January 10, 2000 (26:27 Md. R. 2017)
Regulation .03B amended effective October 15, 2004 (31:20 Md. R. 1486)