[Comment: For dates and availability of material incorporated by reference in this chapter of the Administrative Code, see rule 4766-4-18 of the Administrative Code.]
(A) A MTO applying for initial licensure shall file with the board an "Application for Ambulance or Mobile Intensive Care License" form in the English language, and shall submit the completed application to the board :
(2) With all required supporting documentation as set forth in this rule that must be received by the board.
(B) A MTO applying for renewal of a license shall file with the board a "Renewal Application for Ambulance or Mobile Intensive Care License" form in the English language, and shall submit the completed application to the board:
(2) With all required supporting documentation as set forth in this rule that must be received by the board prior to the expiration date of the license.
(1) The name of service, organizational structure and address of applicant to include 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) Tax identification (tax ID) number or employer identification number (EIN);
(d) All other names under which applicant plans to operate while using the same tax ID or EIN number. Business organizations with different tax ID or EIN numbers cannot operate under the same license;
(e) 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;
(f) Address of physical location of applicant's headquarters (no post office box);
(g) Mailing address of applicant;
(2) All medicare provider numbers ;
(3) All medicaid provider numbers;
(4) Highest level of service to be provided ;
(5) Service areas including county and state;
(6) A list of the names of all officers, directors, and/or owners of the MTO;
(7) The name, contact information, and state of Ohio medical license number of the service's medical director;
(8) For each satellite base, the MTO shall provide the physical address, city, county, state, and zip code;
(9) The name of the primary contact person(s), business or administrative office telephone number, e-mail address, and if applicable, office fax number ;
(10) Year of manufacture, make, model, vehicle identification number, odometer reading, and license plate number (renewal only) of each MoICU or non-transport vehicle to be permitted;
(11) 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 shall accompany application.
(a) Color photographs shall be submitted to the division:
(i) With all initial "Application for Ambulance or Mobile Intensive Care License" forms; and
(ii) Within thirty days of the date a change is made to the vehicle's color scheme, insignia, monogram, or other distinguishing characteristics.
(b) Digital photographs are preferred.
(12) A current and valid certificate of liability insurance in the name of the applicant, listing the board as a certificate holder with a thirty day cancellation notice as specified in section 4766.06 of the Revised Code:
(a) The actual name on the license application shall appear on the certificate of liability insurance;
(b) Each permitted vehicle with vehicle identification number (VIN) shall be listed on the certificate of liability insurance.
(D) An application that is not completed in the manner as specified on the application or does not include all required documentation shall be deemed incomplete.
(E) An application deemed incomplete shall not be considered and may be returned with the notation to the applicant indicating the reason the application is incomplete.
(F) Failure to provide the required documents within thirty days of the date the initial "Application for Ambulance or Mobile Intensive Care License" form is received by the division may result in the application being deemed incomplete.
(G) A MTO shall submit a completed "Renewal Application for Ambulance or Mobile Intensive Care License" form, appropriate fees, and supporting documentation to the board prior to the expiration of the MTO's license in order to be considered timely.
(H) The certificate of licensure issued by the board shall indicate the highest level of service that the MTO is authorized to provide.
(I) No applicant or licensed MTO shall submit false, misleading, or deceptive information in order to obtain a license or permit.
(J) A license is not transferable.
Five Year Review (FYR) Dates: 03/17/2017 and 03/15/2022
Promulgated Under: 119.03
Statutory Authority: 4766.03
Rule Amplifies: 4766.03 , 4766.04, 4766.07
Prior Effective Dates: 04/16/2012