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PT`M�F�r. INDIAN RIVER COUNTY <br />uQPS.�tl►F'� 'p <br />DEPARTMENT OF EMERGENCY SERVICES <br />9�FNp APPLICATION FOR <br />CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY (COPCN) <br />RG Ambulance Service, Inc. d/b/a American Ambulance Sea -9-7 AT11/11/20 <br />APPLICANT NAME] <br />--- - - <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 />Fm 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 [7 ALS <br />Agencies that provide non -emergency ambulance inter -facility medical transport <br />at the ALS/BLS level. <br />Class C ❑IBLS DILS <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 00LS QALS <br />Agencies that provide non -emergency ambulance medical transports limited to <br />out of county transfers. <br />Class E Wheelchair II Wheelchair/Stretcher 7Ambulatory Transport <br />Agencies tat 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 E❑Wheelchair ❑ Wheelchair/Stretcher flAmbulatory 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 />UABeth\Beth Casano EMCOPCN\RENEWAL PACKETS\COPCN Application.doc 21 <br />