(A) A MTO applying for licensure shall file with the board an application on the form prescribed by the board,as published on the board's website at http://omtb.ohio.gov/Forms/Form1.pdf, dated April 16, 2012, in the English language, and shall submit the completed application to the board accompanied by the appropriate fee as defined in rule 4766-2-03 of the Administrative Code.
(1) The name, organizational structure, and address of applicant as follows:
(b) Identification of organizational structure as a corporation (whether for profit or not-for-profit); limited liability company; partnership; limited liability partnership; government unit; or sole proprietor (individual human);
(c) All other names under which applicant plans to operate;
(d) Copies of all trade name registrations and fictitious name registrations for all other names under which applicant plans to operate on file with the Ohio secretary of state;
(e) Address of physical location of applicant's headquarters (no post office box);
(f) Mailing address of applicant;
(2) All medicare provider numbers, all medicaid provider numbers;
(3) Highest level of service to be provided, service areas including county and state;
(4) A list of the names of all officers, directors, and/or owners of the MTO;
(5) The name, address and physician license or certificate number of the medical director as and state of licensure;
(6) For each satellite base, the MTO shall provide the street address, city, county, state, and zip code;
(7) The name of the primary contact person, business or administrative office telephone number, and if applicable, office fax number and e-mail address;
(8) Year of manufacture, make, model, vehicle identification number, odometer reading, license plate number (renewal only) of each ambulance or non-transport vehicle to be permitted;
(9) A color photograph of the side of applicant's vehicle displaying color scheme, insignia, monogram, or other distinguishing characteristic. If multiple color schemes, insignias, monograms, or other distinguishing characteristics are used, a color photograph of each must accompany application. (Digital photographs are preferred);
(10) A current certificate of liability insurance in the name of the applicant listing Ohio medical transportation board as a certificate holder with a thirty day cancellation notice as specified in section 4766.06 of the Revised Code:
The actual name on the licensure application shall appear on the certificate of liability insurance;
(D) If an application for licensure is incomplete, the board will notify the applicant that the application will not be processed until it is complete. Such notification will occur via certified mail one time for each submission.
(E) The certificate of licensure issued by the board shall indicate the highest level of service the MTO is authorized to provide.
(F) Licenses shall be issued to MTOs who meet the criteria to provide the following levels of service:
(1) Basic life support;
(2) Intermediate life support;
(3) Advanced life support.
(G) No applicant or licensee shall submit false statements in order to obtain a license or permit.
(H) A license is not transferable.