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°Epi INDIAN RIVER COUNTY <br />}:.. DEPARTMENT OF EMERGENCY SERVICES <br />e � <br />APPLICATION FOR <br />CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY (COPCN) <br />APPLICANT NAME: Coastal Health Systems of Brevard, Inc. DATE: 02/20/24 <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 />IFICATION 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 to v' 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 />UARRE ADMIN ASSISTANTS\Beth\Beth Casano EOC\COPCN\RENEWAL PACKETS\COPCN Application.doc <br />99 <br />