Laserfiche WebLink
4"rte INDIAN RIVER COUNTY <br />mf° DEPARTMENT OF EMERGENCY SERVICES <br />(Iiiiw " 5APPLICATION FOR <br />CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY (COPCN) <br />APPLICANT NAME: <br />DATE: <br />APPLICATION FEE: $100.00 APPLIES TO INITIAL APPLICATIONS ONLY. <br />If payment applicable, make check payable to INDIAN RIVER COUNTY FIRE RESCUE. <br />El This is a new application; fee is attached. <br />N This is a renewal of our present COPCN. <br />This is a renewal of our present COCPN with ownership or classification changes.. <br />CLASSIFICATION OF CERTIFICATE REQUESTED <br />Please check applicable boxes and options. <br />Class A ❑ _BLS _ALS <br />Governmental entities that use advanced life support vehicles to conduct a pre- <br />hospital EMS ALS /BLS service. <br />Class B El SLS GALS <br />Agencies that provide non -emergency ambulance inter -facility medical transport <br />at the ALS/BLS level. <br />Class C ❑ _BLS _ALS <br />Agencies that provide non -emergency ambulance inter -facility medical transports <br />which rewire special clinical capabilities and require a physician's order. <br />Class D ❑ _BELS _ALS <br />Agencies that provide non -emergency ambulance medical transports limited to <br />out of county transfers. <br />Class E ❑ Wheelchair Wheelchair/Stretcher Ambulatory Transport <br />Agencies that provide wheelchair transportation service only where said services <br />are pard for in part or in whole either directly or indirectly with government funds. <br />Class E1 ❑ Wheelchair Wheelchair/Stretcher Ambulatory Transport <br />Agencies that provide wheelchair vehicle service where said services are not pard <br />for in part or in whole either directly or indirectly with government funds. <br />U:\BetM13eth Casano E©C1COPMRENEWAL PACKETSICOPCN Application.doc <br />83 <br />