Section R9-25-204. Application Requirements for ALS Base Hospital Certification (Authorized by A.R.S. §§ 36-2201, 36-2202(A)(3) and (A)(4), and 36-2204(5))

A.      An applicant for ALS base hospital certification shall submit to the Department an application, in a Department-provided format, including:

1.        A form containing:

a.         The applicant’s name, address, and telephone num- ber;

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 desig- nee 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 pro- vider or ambulance service for which the applicant has a current written agreement described in A.R.S.

§ 36-2201(4);

f.         The name, address, email address, and telephone number of each administrative medical director;

g.        The name of each physician providing on-line medi- cal direction;

h.        Attestation that the applicant meets the requirements in R9-25-202(C);

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 appli- cant’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.

Historical Note

Adopted effective October 15, 1996 (Supp. 96-4). Former R9-25-204 renumbered to R9-25-209; new R9-25-204 made by final rulemaking at 9 A.A.R. 5372, effective January 3, 2004 (Supp. 03-4). Amended by final

rulemaking at 12 A.A.R. 4404, effective January 6, 2007 (Supp. 06-4). Section R9-25-204 repealed; new Section R9-25-204 renumbered from R9-25-208 and amended by exempt rulemaking at 19 A.A.R. 4032, effective Decem- ber 1, 2013 (Supp. 13-4).