Laserfiche WebLink
QTMfti INDIAN RIVER COUNTY <br />m: zb1�DEPARTMENT OF EMERGENCY SERVICES <br />APPLICATION FOR <br />CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY (COPCN) <br />APPLICANT NAME: <br />DATE: /* J - <br />APPLICATION FEE: $100.00 APPLIES TO INITIAL APPLICATIONS ONLY. <br />If payment applicable, make check payable to INDIAN RIVER COUNTY FIRE RESCUE <br />Is is a new application; fee is attached. <br />❑ This is a renewal of our present COPCN. <br />❑ This is a renewal of our present COPCN 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 ❑ _BLS _ALS <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 require special clinical capabilities and require a physician's order. <br />Class D ❑ _BLS _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 onlywhere said services <br />are paid for in part/or in whole either directly or indirectly wigovernment funds <br />Class E1 V' Wheelchair V Wheelchair/Stretcher V Ambulatory Transport <br />Agencies Ifiat provide wheelchair vehicle service where said services are not paid <br />for in part or in whole either directly or indirectly with government funds. <br />U \Beth\Beth Casano EOC\COPCN\RENEWAL PACKETS\COPCN Application doc <br />K <br />