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PTMFNT INDIAN RIVER COUNTY <br /><uQPs �F O <br />DEPARTMENT OF EMERGENCY SERVICES <br />I y •co <br />� U <br />FNCY 5 APPLICATION FOR <br />CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY (COPCN) <br />APPLICANT NAME: <br />Coastal Health Systems of Brevard, Inc. DATE: 3/21/2022 <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 COCPN with ownership or classification changes. <br />CLASSIFICATION OF CERTIFICATE REQUESTED <br />Please check applicable boxes and options. <br />Class A ❑ EIBLS ❑4LS <br />Governmental entities that use advanced life support vehicles to conduct a pre- <br />hospital EMS ALS/BLS service. <br />Class B m WIBLS WIALS <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 ❑ OBLS ❑ALS <br />Agencies that provide non -emergency ambulance medical transports limited to <br />out of county transfers. <br />Class E ❑ ❑Wheelchair ❑ Wheelchair/StretchernAmbulatory 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 ❑ LWheelchair II Wheelchair/StretcherFlAmbulatory 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 />29 <br />