Laserfiche WebLink
P�MFT INDIAN RIVER COUNTY <br />toPS.�, O <br />" g T DEPARTMENT OF EMERGENCY SERVICES <br />9�FNCY APPLICATION FOR <br />CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY (COPCN) <br />APPLICANT NAME: <br />RG Ambulance Service, Inc. d/b/a All County Ambulance DATE] 11/11/20 <br />APPLICATION FEE: $100.00 APPLIES TO INITIAL APPLICATIONS ONLY.. <br />If payment applicable, make check payable to INDIAN RIVER COUNTY FIRE RESCUE. <br />❑ This 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 />I. 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 ❑I:JBLS DLS <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 ❑1D3LS []ALS <br />Agencies that provide non -emergency ambulance medical transports limited to <br />out of county transfers. <br />Class E 7 ❑1 Wheelchair Z Wheelchair/Stretcher ❑Ambulatory Transport <br />Agencies That provide wheelchair transportation service only where said services <br />are paid for in part or in whole either directly or indirectly with government funds. <br />Class E1 001Wheelchair ❑ Wheelchair/Stretcher f]Ambulatory Transport <br />Agencies that 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 15 <br />