Free EMS Provider Application and Operational Plan, DPH 7463 - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health DPH 7463 (Rev. 02/06)

STATE OF WISCONSIN Adm. Code Chapters 110, 111, 112, 113 (608) 266-1568

EMS PROVIDER APPLICATION AND OPERATIONAL PLAN
Completion of this form is mandatory for licensure as an EMS provider. Updating and maintaining a current operational plan with the Department of Health and Family Services (DHFS) is required under Wisconsin Administrative Rule Chapters HFS 110, 111, 112 and 113 and s. 146.50 and 146.55, Wis. Statutes. Failure to complete, submit and obtain approval of an EMS Operational Plan may result in denial, revocation or suspension of an EMS provider license or other disciplinary action as allowed by law. The following apply to EMS service providers per Wisconsin Administrative Codes. Before operating an EMS service, a county, city, town, village, prospective or licensed EMS service provider, hospital or any combination of these shall first submit to the DHFS an operational plan for DHFS review and approval. DHFS approval of the plan shall be a prerequisite to initiation of EMS service provision. Once an operational plan is approved, any modifications must be submitted to the DHFS and approved in writing prior to implementation. Once approved by DHFS, an operational plan becomes the legal description under which an EMS provider must function. No changes may be made without prior written approval of the EMS Section. While some operational plan requirements are standard, some vary with the level of service being provided. Specific operational plan requirements for each level are listed as parts A, B, C, D and E of this application form. Complete the application and operational plan form and continue with your plan by identifying the level of care your service will offer and responding to the plan components for that level. In completing the application, attach additional sheets as necessary. Both form DPH7463 (EMS Provider Application and Operational Plan) and the operational plan component outline for your level of service (DPH7463 part A, B, C, D or E) are required as part of the EMS Service Operational Plan.
RETURN COMPLETED PLAN IN PRINT FORM TO THE APPROPRIATE EMS PROGRAM COORDINATOR AT: This plan is a (check one):
New Change of Service License Level Change of Ownership Special Event Plan Seasonal Plan

Division of Public Health Bureau of Local Health Support and Emergency Medical Services PO Box 2659 Madison, WI 53701-2659

Revised Plan ­ Attach a document describing change and complete only that section applicable to the change. Contact Person (submitting plan) Telephone No. E-mail Address

EMS PROVIDER EMS Provider Information
Provider Legal Name Address (where records are kept) City Day (Office) Telephone No. Mailing Address (If different than above) City DEA number if applicable State ZIP Code County CLIA waiver expiration date State Zip code E-mail Address County Provider License No. FEIN

WI
Other Telephone No.

WI
CLIA waiver number

Service License Level (Check all that apply)
Medical First Responder EMT Intermediate EMT Basic EMT Paramedic Intermediate Technician (formerly IV-Tech and Provisional Intermediate)

DPH7463 (Rev.02/06) Page 2

Type of Ownership (Check all that apply)
Municipality Owned Private Non-Profit * Private For-Profit** Tribal Ownership

*Private Non-Profit ­ Submit A Copy Of Certificate Of Incorporation And A Copy Of Contract For Service ** Private For Profit ­ Submit A Copy Of Contract For Service

Primary Service Area Information (PSA)
List the city, townships or villages you provide primary response.

Attach a map that represents your PSA.

Station Locations
Station Identifier Street Address City Zip

Insurance Information
Professional and or Medical Liability Insurance Provider Name Address City Agent Name Business Telephone No. E-mail Address State Zip Code County Policy No. Expiration Date

Attach a copy of current certificate of insurance. PROVIDER ASSOCIATE INFORMATION Owner Information Owner Name Mailing Address
City Daytime Telephone No. State Other Telephone No. ZIP code County E-mail Address

Service Director/Co-Service Director (Note this individual is the 24 hour/ 7 day contact)
Service Director, Co-Service Director or Chief Operating Officer Name Mailing Address City Daytime Telephone No. State Other Telephone No. ZIP code County E-mail Address License No.

DPH7463 (Rev.02/06) Page 3

Service Director/Co-Service Director (Note this individual is the 24 hour/ 7 day contact)
Service Director, Co-Service Director or Chief Operating Officer Name Mailing Address City Daytime Telephone No. State Other Telephone No. ZIP code County E-mail Address License No.

Medical Director
Medical Director Name Mailing Address City Daytime Telephone No. State Other Telephone No. ZIP code County E-mail Address WI License Number

Attach a copy of the medical director's résumé or curriculum vitae.

Training Officer
Training Officer Name Address City Daytime Telephone No. State Other Telephone No. ZIP Code County E-mail Address

Infection Control Contact Information
Infection Control Contact Name Mailing address City Daytime Telephone No. State Other Telephone No. ZIP code County E-mail Address

Quality Assurance/Improvement Officer
QA or CQI Coordinator Name Address City Daytime Telephone No. State Other Telephone No. ZIP Code County E-mail Address

DPH7463 (Rev.02/06) Page 4

Medical Control Hospital No. 1
Medical Control Hospital Name Address City State ZIP code County

WI
Name of Contact Person
Daytime Telephone No. Other Telephone No. E-mail Address

Medical Control Hospital No. 2
Medical Control Hospital Name Address City State ZIP code County

WI
Name of Contact Person
Daytime Telephone No. Other Telephone No. E-mail Address

STAFFING staffing information (List licensed individuals who take the place of licensed EMS personnel to staff your service.)
RN/PA/MD Name License No. Address City State Zip Code CPR Expiration

staffing information (List licensed individuals who are non-EMS licensed drivers for your service.)
Driver Name WI DL No. Address City State Zip Code CPR Expiration

DPH7463 (Rev.02/06) Page 5

AFFILIATES (For Ambulance Service Providers) Interface With Medical First Responder Groups
Do you have written agreements with Medical First Responder agencies? Name Yes Name No

AFFILIATES (For Medical First Responder Services) Interface With Ambulance Service Providers
Do you have written agreement with ambulance service providers? Name Yes Name No

Mutual Aid Agreements (written backup agreements, mutual aid, ALS intercept, tiered response)
Name Describe relationship

TRANSPORTATION List All Vehicles Used by this Service
Local Unit No. WI License Plate No. VIN Year/Make Model Conversion Mfg. Vehicle type Date last DOT Inspection

DPH7463 (Rev.02/06) Page 6

SIGNATURE PAGE TO ACCOMPANY FORM DPH7463
Name of EMS Provider Provider License Number

OWNER/OPERATOR CERTIFICATION 1. I certify that the information submitted on form DPH 7463 is true and complete to the best of my knowledge. I further certify that the named EMS service will operate in conformance with s. 146.50 and s. 146.55, Wisconsin Statutes and Chapters 110, 111, 112 and/or 113 Wisconsin Administrative Code. 2. The EMS service will comply with the specifications and standards of the Wisconsin statewide emergency medical services communications system. 3. The EMS service will use the Department's run report form or a copy of an alternative report form will be provided to the Department for review and approval prior to its use. All runs will be documented on this ambulance report form and all forms will be kept and distributed in compliance with Wisconsin Statutes and Administrative Codes pertaining to patient medical records.

SIGNATURE - Owner * SERVICE DIRECTOR CERTIFICATION

Date Signed

1. I certify that the information submitted on form DPH 7463 is true and complete to the best of my knowledge. I further certify that the named EMS service will operate in conformance with s. 146.50 and s. 146.55, Wisconsin Statutes and Chapters 110, 111, 112 and/or 113 Wisconsin Administrative Code. 2. The EMS service will comply with the specifications and standards of the Wisconsin statewide emergency medical services communications system. 3. The EMS service will use the Department's run report form or a copy of an alternative report form will be provided to the Department for review and approval prior to its use. All runs will be documented on this ambulance report form and all forms will be kept and distributed in compliance with Wisconsin Statutes and Administrative Codes pertaining to patient medical records.

SIGNATURE - Director * MEDICAL DIRECTOR CERTIFICATION

Date Signed

I certify that I am willing to participate in the above named EMS services' program and fulfill the responsibilities of medical director as described in this plan and to adhere to the requirements of Chapters 110, 111, 112 and/or 113, Wisconsin Administrative Code. Additionally, I certify that the attached medical protocols for this EMS service provider have been reviewed and approved by me.

SIGNATURE - Medical Director QUALITY ASSURANCE CERTIFICATION

Date Signed

I certify that the EMS service is willing to participate in a data collection program, collect EMS data and to submit that data to the Department as requested.

SIGNATURE - Quality Assurance Representative * TRAINING CENTER CERTIFICATION

Date Signed

I certify that this EMS Training Center is willing to participate in the above named EMS services' program and fulfill the responsibilities and requirements as described in this plan and to adhere to the requirements of Chapters 110, 111, 112 and/or 113, Wisconsin Administrative Code. SIGNATURE - Training Center Representative Date Signed

DPH7463 (Rev.02/06) Page 7

Name of Ambulance Service Provider MEDICAL CONTROL HOSPITAL CERTIFICATION

Provider License Number

I certify that this hospital is willing to participate in the above named EMS services' program, providing on-line medical direction by a Wisconsin licensed physician 24 hours/7 days per week. Additionally, I certify that the facility will fulfill the responsibilities of medical control facility as described in this plan and adhere to the requirements of Chapters 110, 111, 112 and/or 113, Wisconsin Administrative Code.

SIGNATURE - Medical Control Hospital Representative

Date Signed

MEDICAL CONTROL HOSPITAL CERTIFICATION I certify that this hospital is willing to participate in the above named EMS services' program, providing on-line medical direction by a Wisconsin licensed physician 24 hours/7 days per week. Additionally, I certify that the facility will fulfill the responsibilities of medical control facility as described in this plan and adhere to the requirements of Chapters 110, 111, 112 and/or 113, Wisconsin Administrative Code.

SIGNATURE - Medical Control Hospital Representative

Date Signed

RECEIVING HOSPITAL CERTIFICATION I certify that this hospital is willing to participate in the above named ambulance services' program and fulfill the responsibilities of receiving hospital facility as described in this plan and to adhere to the requirements of Chapters 110, 111 and/or 112, Wisconsin Administrative Code.

SIGNATURE - Receiving Hospital Representative

Date Signed

RECEIVING HOSPITAL CERTIFICATION I certify that this hospital is willing to participate in the above named ambulance services' program and fulfill the responsibilities of receiving hospital facility as described in this plan and to adhere to the requirements of Chapters 110, 111 and/or 112, Wisconsin Administrative Code.

SIGNATURE - Receiving Hospital Representative

Date Signed

* AFFILIATED AMBULANCE SERVICE CERTIFICATION I certify that the above named Medical First Responder group is part of our tiered response.

SIGNATURE - Ambulance Service Director

Date Signed

* AFFILIATED AMBULANCE SERVICE CERTIFICATION I certify that the above named Medical First Responder group is part of our tiered response.

SIGNATURE - Ambulance Service Director *Identifies signatures required for Medical First Responder services.

Date Signed