Massachusetts Department of Public Health
Office of Emergency Medical Services

Ambulance Service License Application
General Instructions

This application is divided into the following six parts:

	Part A  			Ambulance Service License Application Form (pages 1&2)
	Part B-1  		Service Area Form
	Part B-2  		Back up Ambulance Services Form
	Part C 			EMS Personnel List
	Part D  			Place of Business Form
	Part E  			Vehicle Certification Form
	Part F 	 		Survey Information Form (when requested)
	Part H			Affiliation Agreement Review

The purpose of the modular design of the application packet is to enable providers to complete only the part(s) that provide information necessary for the particular action being requested.  Thus, when a new license is to be issued or an existing license is to be renewed, information from all parts of the application packet is needed.  If, however, an ambulance vehicle is being replaced or added to a service, only the Application for Certification Inspection, Part E, is necessary.

It is intended that Parts B and D be used to notify OEMS of any changes either in the regular operating area (including changes in back-up arrangements) or in any of the service’s place of business (change in type of service conducted from that location, a new garage location, re-location of company headquarters, for example).

Other important changes that need to be reported to OEMS that may or may not require completion of an application form(s) include change in ambulance classification, corporate ownership, mailing address, telephone numbers (emergency and business), service manager, etc.  Substantive changes in information that has been provided on application forms must be reported to OEMS as they occur.  Some changes require modification of ambulance service license via action by the Public Health Council; some need to be documented in writing; and others need only verbal reporting to OEMS.  If there is any question about what the requirements are, please call either the Inspector for your service or the Manager of the Ambulance Regulation Program at OEMS.

Initial Application or Relicensure Application

1.	Complete Parts A, B, C, D and E
If you are applying for an ambulance service license for the first time, or if you are renewing you ambulance service license, you must complete parts A, B, C, D and E and remit appropriate fees before your application can be reviewed for licensure.

Depending upon the particular structure of your service, you may need additional copies of Parts B, C, D and/or E. Part B provides spaces for 10 communities in which you normally provide service (other than back-up) and for 8 ambulance services from whom you receive back-up.  Part C allows space for 17 EMS personnel.  You will need to complete a Part D for each and every location where the ambulance service conducts business.  Finally, there must be a Part E, Applications for Certification Inspection of Ambulance, submitted for each vehicle that you operate as an ambulance.  PLEASE MAKE AS MANY COPIES OF THESE FORMS AS YOU NEED TO COMPLETE THE APPLICATION FOR YOUR SERVICE.

2.	Part F, The Survey Information Form

Part F, the Survey Information Form, although optional, will provide important data on current topics to OEMS for analysis.  The questions asked in Part F would change as topics of concern and interest vary.  Although failure to complete this form will not cause a delay in referring your license application for Public Health Council action, we DO encourage you to complete the survey and return it with your application materials.

3.	Fees

With your completed application packet, remit the appropriate fee(s) or a letter explaining why submission of the fee(s) will be delayed.  Please be aware that your application cannot be referred for licensure unless the appropriate fee(s) has been received.  The fee for ambulance service licensure is $400 for BLS, Initial or Renewal; $600 for ALS, Initial, Renewal or upgrade.  The fee for vehicle certification inspection is $200 for each vehicle. Make checks payable to: Commonwealth of Massachusetts 

4.	Proof of insurance

With your license application and fee, you must submit proof of contracts of insurance, which shall be held confidential by the Department.  Minimum levels of insurance required on each ambulance are defined by Section 170.315(B) as follows: $100,000 on account of injury to or death of any one person; subject to the limit as respects injury to or death of one person, $500,000 on account of any one accident resulting in injury to or death of more than one person; and $25,000 because of injury to or destruction of property of others in any one accident.

5.	Additional Information
Initial applicants must submit, in addition to the information listed above, the following:
a.	A Notice of Intent (enclosed);
b.	Letter of endorsement from highest elected/appointed municipal official (for municipal applicants);
c.	A Certificate of Good Standing for the applicant from the Secretary of State’s office from the state in which the corporate headquarters are located (for private and corporate applicants);
d.	A Certificate of Good Standing from the Department of Revenue of the state in which the applicant resides
                /or the corporate office is based (for private and corporate applicants);
e.	A list of all officers, directors, shareholders and operation managers of the applicant;
f.	A current copy of the Articles of Organization of the applicant, and
g.	Other information that is deemed necessary pursuant to the Department’s review of the submitted material.

REPLACEMENT OR ADDITIONAL VEHICLE CERTIFICATION
Each vehicle that you add to your service and each replacement vehicle must be certified BEFORE being put into operation.  For each additional or replacement vehicle submit a completed Part E, Application for Certification Inspection of Ambulance as soon as the vehicle information is available to you.  

If you are only adding or replacing a vehicle, you will need to submit only the Part E form (one for each vehicle) and the appropriate fee of $200 per vehicle.

The Application for Certification Inspection for a replacement vehicle with the appropriate fee MUST be received by OEMS within three business days of the date the replacement ambulance is put into operation.  OEMS shall issue a temporary certificate of inspection for the class of ambulance as indicated on the application.  The temporary certificate will be valid until you receive the regular certificate of inspection (or until you receive a notice of denial of certification).  If the classification of the replacement vehicle is different from that of the vehicle being replaced, the ambulance service license shall be modified accordingly to reflect the change.

If the new ambulance is an addition to those authorized under the ambulance service license, a temporary certificate valid for up to ninety days may be issued upon submission of application and fee.

PRE-DELIVERY INSPECTIONS
There is no application form required to arrange for a pre-delivery inspection of a new ambulance.  In order to qualify for a pre-delivery inspection, a vehicle should be ordered to comply fully with KKK-A-1822.  There must be no exceptions taken to the specification unless the service has received a waiver from OEMS prior to placing the order.  The service must provide a copy of the bid specification and/or purchase agreement before a pre-delivery inspection can be scheduled.  Allow at least three weeks notice to OEMS to schedule a pre-delivery inspection.  Because of restrictions on out-of-state travel, pre-delivery inspections must be conducted at locations within Massachusetts.

TERM OF LICENSE
The standard term of licensure for Basic Life Support (BLS) services is two years, and the standard term for Advanced Life Support services is one year.  Pursuant to 170.230(E) of the EMS Regulations, however, a license shall remain in effect for a period of 12 to 24 months at the discretion of the Department.  In other words, the Department has the ability to issue an ALS license valid for up to two years, and may issue a BLS license valid for less than two years.  It is important that you note the date of expiration on your ambulance service license to define precisely the term of your license.  

Provided that services submit applications in a timely manner, the Department generally is able to act on renewal licenses within sixty days of receipt of all necessary application documentation. If the Department is unable to take action on a properly submitted relicensure application within sixty days, the service may continue to operate until the Department does take that action.  It is important to note that if a service fails to submit a complete and acceptable application for renewal in a timely manner, the service may NOT continue to operate past the expiration date without written permission by the Department.  –See EMS Regulations, 170.230 (C).

A provisional license may be issued to a service who does meet the requirements of the EMS Regulations provided the service (1) has demonstrated good faith intention to meet all requirements, (2) is providing adequate emergency medical care, (3) evidences a potential for full licensure within six months.  Provisional licenses expire six months after the date on which they are issued.  A service may not be issued any more than two consecutive provisional licenses.  

AUTHORIZED SIGNATURE
The application must be signed by someone who is duly authorized to do so; the authorized signature attests to (1) the completeness and accuracy of all information provided, (2) the Statement of Non-Discrimination, and (3) the Tax Certification Statement (non-governmental services only); along with the completed, signed application (Parts A, B, C, D and one Part E for each vehicle) the following are to be submitted for review:

1.	Proof of insurance
2.	Remittance of fees
3.	Letters for any waiver(s) you wish to have extended