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Home My WebLink About20130590.tiffDEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT 1555 North 17th Avenue Greeley, Colorado 80631 Web: http://www.weldhealth.org Health Administration Vital Records Tele 9703046410 Far. 9/0 304 6412 Public Health & ClinIcal Services Tele 970 304 6420 Fax 970 304 6416 Public Health Environmental Health Communication, Emergency Preparedness Services Education & Planning & Response Tele: 970 304 6415 Tele: 970 304 6470 Tele: 970 304 6420 Fax 970 304 6411 Fax 970 304 6452 Fax: 970 304 6469 Our vision Together with the communities we serve, we are working to make Weld County the healthiest place to live, learn, work and play Memorandum Date: February 6, 2013 To: Commissioners From: Mark E. Wallace, MD, MPH — Director Re: Ambulance License Appeal, Poudre Valley Hospital EMS The Department of Public Health and Environment has reviewed the "Appeal of Denial of Ambulance Service License Application Submitted by Poudre Valley Hospital EMS", dated January 21, 2013. The appeal was submitted in response to the Department denying Poudre Valley Hospital EMS (PVH EMS) application for an Ambulance Service License. The Ambulance Service License was denied in a letter dated December 21, 2012, to Steve Main at PVH EMS, from the Director of the Weld County Department of Public Health & Environment, Dr. Mark E. Wallace. The letter of December 21, 2012, outlined two reasons for denial: #1. PVH EMS does not have its primary base of operation located in Weld County, as required by the definition of "ambulance service license," found in Section 7-1-30 of the Weld County Code, and, #2. PVH EMS is not providing "primary care" in Weld County, as defined in said Section 7- 1-30, because it does not have an agreement or contract with Weld County to do so. PVH EMS has attempted to address the two deficiencies noted above. Each item is addressed separately below: PVH EMS Response to #1: On page 2, item 6., of their appeal request, PVH EMS indicates that they have "...established its primary base of operation for its Weld County ambulance service at 6906 Tenth Street, Greeley, Colorado 80634, an address located within the County." WCDPHE position: As PVH EMS has indicated their primary base of operation is in Weld County the Department no longer has issue with this deficiency. PVH EMS Response to #2: On page 2, item 7, of their appeal request, PVH EMS indicates that they "...are presently negotiating, or has entered into, ambulance and emergency medical service agreements with the Windsor -Severance, Johnstown, and Milliken Fire Protection Districts (the "Fire Districts"). Each of the Fire Districts is located within the County. See Exhibit D." Page 1 of 2 2013-0590 #Z O0 41/ WCDPHE position: PVH EMS has not provided the WCDPHE any agreement or contract to provide emergency medical service related to this license application. Had PVH EMS provided an agreement or contract with a Fire District or municipality, the Department would consider this deficiency to be satisfactorily addressed. However, Exhibit D did not include a contract or agreement with the Fire Districts, only a Affidavit of Steve Main. The Department does not consider Mutual Aid agreements adequate to fulfill this deficiency. The Department contends that this deficiency has not been adequately addressed. WCDPHE Recommendation: Issue a Tier I license with a condition limiting emergency medical service to Mutual Aid response. Please do not hesitate to contact me should you have any questions or concerns. cerely, Mark E. Wallace, MD, MPH Executive Director and Health Officer Page 2 of 2 POUDRE VALLEY HEALTH SYSTEM VIA HAND DELIVERY January 21, 2013 Monica Daniels -Mika Clerk to the Board of County Commissioners 1150 O Street P.O. Box 758 Greeley, Colorado 80632 Telephone: (970) 336-7215, ext. 4225 RE: Appeal of Denial of Ambulance Service License Application Submitted by Poudre Valley Hospital EMS Dear Ms. Daniels -Mika: In accordance with Weld County Code Sec. 7-2-140, Poudre Valley Hospital EMS ("PVI I") hereby submits its appeal of the denial of its Ambulance Service License Application (the "Application") as follows: Facts 1. On November 8, 2012, PV I I submitted its Application to the Weld County Department of health (the "Department") seeking licensure to provide advanced life support ambulance services in Weld County (the "County"). See Exhibit A.' 2. In and with the Application, PVH provided the Department all of the information, and paid each of' the fees, requested by the County and referenced in its Ambulance Renewal Process Checklist. Nowhere in the Application or its accompanying instructions was PVH directed to describe the contracts or agreements in accordance with which it provides "primary care," as defined in Weld County Code Sec. 7-1-30, within the County. 3. On December 21, 2012, the Department's Executive Director and Ilealth Officer, Mark E. Wallace, M.D. (the "Director"), issued a letter denying the Application. In that letter, Dr. Wallace stated that the Application was being denied because: J alcolm Baldrige Nalill.i Qualily award ood Award Recipient 2315 East Harmony Road, Suite 200 • Fort Collins, Colorado 80578 • Phone: (9701237-7030 • Fax (970) 237-7093 • www.pvhs. org Poudre Valley I lospital EMS (PVH EMS) does not have its primary base of operation located in Weld County, as required by the definition of "ambulance service license," found in Section 7-1-30 of the Weld County Code, and, PVII EMS is not providing "primary care" in Weld County, as defined in said Section 7-1-30, because it does not have an agreement or contract with Weld County to do so. See Mark E. Wallace letter to Steve Main (December 21, 2012) (attached as Exhibit B). 4. On or before May 30. 1990. PVH began providing "primary care_' as defined in Weld County Code Sec. 7-1-30, in accordance with a Mutual Aid Agreement with Weld County Ambulance Service. Section 9 of the Mutual Aid Agreement provides that it shall remain in effect until 60 days written notice of termination from one party to the other. See Exhibit C. To date, neither party to the Mutual Aid Agreement has given notice of its intention to terminate that Agreement. See Affidavit of Steven C. Main (attached as Exhibit D). 5. PVII has been advised by the Office of the Weld County Attorney' that similar mutual aid agreements served as the exclusive basis for granting ambulance service licenses to other, similarly situated providers in December of 2012 and in previous years, including Platte Valley Medical Center. Thompson Valley EMS, Mountain View Fire Protection, Stadium Medical and Motocross Medics. See Exhibit D. 6. PVH established its primary base of operation for its Weld County ambulance service at 6906 'Tenth Street. Greeley, Colorado 80634, an address located within the County. See Exhibit D. 7. PVI-I is presently negotiating, or has entered into, ambulance and emergency medical service agreements with the Windsor -Severance, Johnstown, and Milliken Fire Protection Districts (the "Fire Districts"). Each of the Fire Districts is located within the County. See Exhibit D. Applicable Ordinances 8. Weld County Code Sec. 7-2-100 provides that: the Director shall issue a license to Ian Ambulance Service License Applicant) to provide ambulance service and a permit for each ambulance used upon a finding that: A. The ambulance service staff, vehicles, equipment and location comply with the requirements of [Weld County Code, Chapter Seven]: B. The ambulance service's emergency medical technicians are certified in accordance with the rules pertaining to emergency medical services of the Colorado Department of Public Health and Environment; and C. The applicant has complied in all respects with the requirements of [Weld County Code, Chapter Seven]. See Weld County Code Sec. 7-2-100 (emphasis added). 9. Weld County Code Sec. 7-1-30 states that an Ambulance Service License "shall issue only to ambulance services whose primary base of operations is located in the County or whose operation includes providing primary care in the County." See Weld County Code Sec. 7-1-30 (emphasis added). 10. Section 7-1-30 further defines the term "primary care" to mean "the initial response and care for emergency medical services. either h1' contract or agreement." See Weld County Code Sec. 7-1-30 (emphasis added). Argument 11. In his letter of December 21. 2012, the Director indicated that he was denying the Application for two — and only two -- reasons: (1) that PVII did not maintain a primary base of operation in Weld County: and (2) that PVI I did not provide primary care in Weld County, as defined by Sec. 7-1-30, "because ]PVH] does not have an agreement or contract with Weld County to do so." See Exhibit B. Providing Primary Care by Contract or A recment A. Weld County Code Sec. 7-1-30 establishes that, for purposes of Code Chapter Seven, "primary care" means providing initial, emergency medical services response and care "either by contract or agreement." B. As set forth in the attached affidavit of PVII EMS Manager Steve Main, PVH has long maintained a Mutual Aid Agreement through which it has provided primary care within Weld County. C. Therefore, contrary to the Director's finding, PVII satisfies one of the two alternative prerequisites to ambulance service licensure in that, by agreement, it provides primary care in the County. D. As a consequence, Weld County Code Section 7-1-30 mandates that the Director issue an ambulance service license to PVFI, as he has to other, similarly situated ambulance service providers. Any other result would contravene the guarantees of equal protection of law afforded by both the state and federal constitutions. See, e.g., City of Colorado Springs r. Weber, 791 P.2d 1162, 1 163 (Colo. App. 1989) (guarantee of equal protection requires that government treat similarly situated persons in a similar manner). E. The Director's denial of PVIA's Application also contravenes the statutory authority of lire protection districts to provide ambulance services within their boundaries. Specifically, C.R.S. § 32-I-1002 (1) (e) provides the board of any lire protection district authority to undertake and operate an ambulance service and an emergency medical service as part of its duty to provide lire protection within the district. Whether to provide ambulance and emergency medical services through district employees, through a contract with a third party, or through a combination of the two is within the discretion of the district. See City Council of the City of Greenwood pillage r. Board of Directors of South Suburban Metropolitan Recreation & Park Dist, 509 P.2d 317, 319 (Colo. 1973) (acknowledging local governmental entity has the right to provide services either directly or by contract at its choosing): City of Westminster v. Hyland Hills Aletropoliran Park & Recreation Dist., 550 P.2d 337, 339 (Cola 1976) (Greenwood Village v. South Suburban addressed the fact that no substantial difference exists between local government contracting with a third party to provide services and providing those services itself). P. Moreover. Colorado law prohibits a county government from enforcing a county ordinance or other exercise of county authority within the boundaries of a tire protection district "if such ordinance . . . or exercise of an authorized power would duplicate or interfere with any service or facility' authorized and provided by such [tire protection district], unless the county is specifically empowered by law to exercise authority with respect thereto. or the county and the special district agree otherwise C.R.S. § 30-15-401 (9) (a). G. Here, the Director's expansion of Code Section 7-1-30's definition of "primary care- beyond the plain meaning of its terms, thus potentially prohibiting the Fire Districts from contracting with PVI1, is directly contrary to Section 30-15-401 (9) (a). Moreover, nothing in Colorado law specifically empowers the County to interfere with the Fire Districts' exercise of their lawful authority to contract for ambulance and emergency medical services by applying a new and unpublished rule limiting licensure to ambulance services that both maintain a primary base of operation in the County and provide primary care through a contract with the County. II. For all of the reasons set forth above, PVH satisfies the ambulance licensing requirement that it provide primary care in the County, either by contract or agreement. The Director's finding to the contrary violates the Weld County Code, as well as both state and federal law. The Commission should therefore reverse the Director's denial and grant PVl I's Application. Maintaining a Primary Base of Operation in the County 1. PVII notes that the Weld County Code does not define the term "base of operation" for purposes of Chapter Seven. Rule 2.1 of the Rules Pertaining to Licensure of Ground Ambulance Services promulgated by the Colorado State Board of Health, however, defines the term "based" to mean "headquartered, having a substation, office ambulance post or other permanent location in a county." See 6 CCR 1015-3, Chapter 4, Section 2, Rule 2.1. J. As of the date upon which this appeal is tiled, PVII primarily' bases its ambulance service for Weld County at 6906 Tenth Street, Greeley, Colorado 80634, an address located within the County. Sec Exhibit D. K. The Commission should therefore reverse the Director's contrary finding of fact and grant PVII's Application. Conclusion 12. In accordance with applicable ordinances of the Weld County Code, PVH maintains a primary base of operation for its Weld County ambulance service at an address located within the County. Further, PVT! provides primary care within the County in accordance with its Mutual Aid Agreement with the County. The Director was therefore in error to deny PVII's Application. As a consequence, PVII respectfully requests the Commission to reverse the Director's denial of its Application and to grant it the Ambulance Service License for which it applied. Respectfully submitted this 21" day ofJanuary2013 POt1DRE VALLEY HOSPITAL EMS By: 71Art l/ Amy Kolczak General Counsel Poudre Valley hospital cc: Mark E. Wallace, MD, MPH The full PVH Application for licensure included 313 pages of PVH EMS protocols. Due to the volume of those documents, they have not been reproduced here but PVH is happy to produce them to the Weld Board of County Commissioners if so desired. EXHIBIT A Poudre Valley Hospital EMS Ambulance Service License Application (without attachments) Page 2 DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT 1555 North 17th Avenue Greeley, CO 80831 Web; tvtvw,weldhealth.oro P77bu �Fiesrth Hestia MminlelMllen Futile Heirs Medial cndnmment.l Hearne Cemmunleelen, Ern/fiat Peep.Mdnu. VIM Records Snake; Service. Deetnllen 6 Planning d Response Tee: 070104e110 relic 910204,14W Tell: 910,331,8416 Tel.:9703M60D Us: 970.304.1420 Fee 070,301.&12 Fax 910,3016116 En 010301.6111 Fee 070,3846162 Fee 91a3M 6160 Our delve. Tostl6N nbb the mold* la um, we.mnu#rp to oils I* aCOONyen. beaChkrip.4.e lo Iv; him, R9r6andFin AMBULANCE SERVICE LICENSE APPLICATION ... .. r�Data.v(applicatlon: Name of AmbulanceServlce: Peoc^L xi alb j I'1 -d -At, ---e I M S Owner: (� ,1n (� Name: 4 0 JC Ua te•IM� Hi Ad A.0, -.a ,SL e Address: a 3/ 5 /= ��. r. r' 1 Rr{• tv:'er at) n Phone Number: (97O2; 2_ -/7 S Oneratlons Manager: Name: Jtv A , (a&r't P.. -- Address: /01-i f. 7-...••.a +Jp . Phone Number: )1/ 9 c —LS'0/ 9 Pursuant to Section 7-2-150 of Wald County Code Ordinance, any change of ownership requires a new application for ambulance service license. Dale Received: / / (For Office Use Only) Documents Checked; Remarks: Approved Recommended (Y/N): Date Referred to B.O.C.C,: / / Licensing Agent Page 3 Name and address of each stockholder of pettier owning 10% or more of the outstanding stock of the company of having more than a 10% ownership interest (if applicable): What area of Weld County will be served by this company? ?lease attach a map indicating the service area. Haw many ambulances do you operate? / r5? Location and description of the place(s) from which this ambplance syynn icvvill operate. If there are more than two locations, attach a separate sheet with the above information, Se —C- 0-444- cl�a ce Location #1: Street Number: City: State: Phone: Location ff2; Sheet Number: City: State: Phone; Medical Director: Name: l )i4 .- f Mailing Address: (C-3 cir Phone Number; (970yc s'— Please read carefirlly Ft. otLeiL, Cd 7.2.170 Annual renewal, MI licenses and permits shall be renewed annually, shall expire on December 31 ofihe year issued, and shall not be renewed until the application has been approved by the Department. All applications for renewal of licenses and permits shall be made rot later than sixty (60) days prior to the date ofexpiration. The Department shall notify, by certified mall, return receipt requested, each licensee of the renewal requirements of this section within ninety (90) days prior to the date of expiration (Weld County Code Ordinance 2007.8) 7.2.160 Change of hfedical Director An ambulance service must report any change of medical director, including name, address and telephone number, to the Director within fifteen (IS) calendar days of such change, (Weld County Code Ordinance 2007.8) Page 4 Please read carefully and provide the following: G. As required in Section 7-2.90 (G) of the Weld County Code Ordinance, a list of all emergency medical service providers who may be called upon to respond to an emergency with the ambulance service. This list shall include the following information on each person: 1. Complete name, address and date of birth 2. The highest level ofcetification, licensure or training attained. 3. A copy of current EMT -B, EMT -I or EMT -P certificate issued by the Colorado Department of Public Health and Environment; nurse licensure or an Advanced First Aid card from the American Red Cross; or a First Responder course completion certificate issued by a Division -recognized training center or training group. 4. Proof of valid Colorado driver's license. 5. A statement of criminal complaint or convictions, including Class I and II traffic violations, within the previous twelve (12) months. H. As required in Section 7-2-90 of the Weld County Code Ordivance„Proof of insurance, as required in section 7-3.60 of this Chapter, (Worker's compensation insurance, Public liability and property damage bodily injury, Property damage, Professional liability, and Ambulance vehicles coverage.) As required in Section 7-2-90 (I) of the Weld County Code Ordinance, provide a current copy of EMT or Paramedic protocols adopted by the ambulance service In accordance with standards approved by the ambulance service's medical director. As required in Section 7-2-90 (J) of the Weld County Code Ordinance, provide a current copy of the ambulance service's training standards in accordance with the requirements approved by the ambulance service's medical director. All training must be through a stale -certified emergency medical services training center. K. As required in Section 7-2-90 (K) of the Weld County Code Ordinance, make available for review by the Department current records of compliance with the current EMS Laws. L. As required In Section 7-2-90 (L) of the Weld County Code Ordinance, copies of any judgments entered against the licensee or license applicant within the previous twelve (12) months, including findings of fact, conclusions of law and order by any court or other tribunal. M. As required in Section 7-2-90 (M) of the Weld County Code Ordinance, such other information as the Department may require to make a fair determination. N. As required in Section 7-3.110 of the Weld County Code Ordinance, make available for review by the Department evidence of a medical. continuous quality improvement program consistent with the requirements defined in the Colorado Board of Medical Examiners rules, 3 C.C.R § 713-6, Rule 500, 3,2, b. (Weld County Code Ordinance 2007-8) O. As required in Section 12,9.2 E lof the Colorado Rules Pertaining to Emergency Medical Services, provide a current copy of the ambulance service's pharmacological agents and delivery devices per medical director protocol. * Please note Section 7-3-50 Criminal record of ambulance crew member. Unless waived by the Board of County Commissioners, no person shall be employed by an ambulance service as an ambulance crew member who has been convicted of any of the following offenses within the previous twelve (12) months from the date of application: felony, misdemeanor or Class i or Class II traffic offense. Page 5 I HEREBY CERTIFY THAT I AM AUTHORIZED TO SUBMIT THE FORGOING APPLICATION AND THE INFORMATION PROVIDED IN THIS APPLICATION IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF AND CONTAINS NO WILLFUL MISREPRESENTATION OR FALSIFICATION. IN ADDITION, I CERTIFY THAT IHAVE READ AND UNDERSTAND THE PROVISIONS AND REQUIREMENTS OF WELD COUNTY CODE CHAPTER 7, INCLUDING, BUT NOT LIMITED TO, SECTION 7-8- l0, WHICH ENCOURAGES ALL LICENSED AGENCIES PROVIDING EMS RESPONSE IN WELD COUNTY TO MAKE A GOOD FAITH EFFORT TO EXECUTE WRITTEN MUTUAL AID AGREEMENTS WITH ALL OTHER EMS PROVIDERS LOCATED WITHIN OR BORDERING ON THEIR AREAS OF RESPONSE, DETERMINATION THAT AN AMBULANCE SERVICES LICENSE HAS BEEN ISSUED BASED ON FALSE. INFORMATION CONSTITUTES GROUNDS FOR LICENSE REVOCATION AND POSSIBLE CRIMINAL PROSECUTION. Deft SUBSCRIBED AND AFFIRMED BEFOREME THIS �j kh DAY , �C yyl .Y 20 1 . IN THE COUNTY OF .`Z4:; Oy�� STATE .FCOLORADO. Le yNOTAPki V -i4 04llig s„, My Commission expires: ( Signetu Page 9 AMBULANCE RENEWAL PROCESS CHECKLIST Complete Ambulance Service License Renewal Application Map of service area I. Location (s)/Description(s) where ambulance operate from Medical Director Name/Address/Phone Number Is this a change from last year? Yes No List of emergency medical service providers Complete Name, address, date of birth Highest level of certification, licensure or training Copy of current EMT -B, EMT -I, EMT -P, Nurse licensure, Advanced First Aid, First Responder Proof of valid Colorado driver's license Statement of criminal complaint or convictions, including Class I and II traffic violations, ' within the previous twelve (12) months laticv— L eel '4" Proof of insurance l Current copy of EMT or Paramedic protocols ac-. • WW1 t. ----Current copy of ambulance service training standards &1A Copies of and judgments entered against licensee or license applicant within the previous twelve (12) months, including findings of fact, conclusions of law and order by any court or other tribunal. Such other information as the Department may require to make a fair determination. `Evidence of a medical continuous quality improvement program Medication and Delivery Device List (Please update as needed) Notarized signature on page 4 of renewal application Over —� Page 10 Complete Ambulance Vehicle Permit Renewal List Year, Make, Model, d wheel drive (yin) V.I.N d, Registration N, Chassis tl `--'`Registered in Colorado as Emergency Vehicle (yin) Date ambulance placed In service /�.,.�� Normal location A/"J(17:-C":-,<-11 �-" Ambulance Service License Fee ($100.00) Vehicle Permit Fee (s) ($25.00 each vehicle) Client: 12662 PVI(EA ACORDI4 CERTIFICATE OF LIABILITY INSURANCE D3IB281O12wl THIS CERTIFICATE I9 ISSUED A8 A MATTER OP INFORMATION ONLY AND CONFERS NO 11101118 UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURBR(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER, IMPORTANT; if file anlllcalo holder la an ADDITIONAL INSURED, the polley(lee) mu it ha endorsed. f( SUBROGATION IS WAIVED, subplot to the terms and conditions of lha policy, cumin Regalia may requlre on endorsement. A satament on Ible aerillioete does not miler right. to the certificate holder in lieu of sueb endoresment(s), PROMISEE Flood & Paterson Ina„ Ino, P.O. Box 678 Greeley, CO 80632 970 968.0129 ,�Q1 Neioikki M 0.7123kor a6.Ih 970 28807129 lattok 970 600.8829 art 33, nIkkLmoebruckar64fIoodandpaloraon,00m papsoash W�ONrahDn INfUPIA AffORONO COVERAGE NAM! Memo Paudre Valley Health Care, Ina. dbe Poudre Volley Health System 2915 E Harmony Road, Suns 200 PMCollins, Co 80528.8820 ..............e ..._ INlam A; Copia Companies mama, Solely National Casually Compon Mann Of MUMS o, 'NUM I I IMSUPear; — -RE VISIONNUMBER; Inca u IOOMHnm', THAT THE POLICIES OF INSURANCE LISTED OELOW HAVE 06 EN ISSUED TO THE INSURED NAMED ABOVE FOR THa POLICY PEnl00 INDICATED. NOTWITHSTANDING ANY REQUIREMENT, ;EMI OR coal TFOR OF ANY CONTRACT OR OTHER DOCUMENT Willi RESPECT TO WHICH Tills CERTIFICATE MAYBE ISSUED OR MAY PERTAIN/MC INSURANCEAFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS BROWN MAY MVO OE EN REDUCED PAID CLAIMS. N9R TYPO OFURUMNCE Ma HEWN° WE FULIoYNullnsn ClIp yBY tlQI�V &i,1.00(i HVtl LIMES A efNEMLLua1HlY 11CC00O8s22 34101/2012 04101/2019 PACHOCCURA.EMCE 11 000.000 X COMMERCIAL OENEMI LMOMIrY PRFkISE (EJ Onu,Naw) s600,000 AlCLHMSA'DE E OCCUR MEOUP (Mycoop OF^1 05,000 X Malpractice Reiro Dole; PERSONAL% MVINJVAY 71 000j000 Liability 6/1/1SO4 OENIIALM1OREOAIE !9,000,000 OEIJL AOCRMOATELIVRMPLIEIPIN PACOVO/E • COW.'CP A00 71,000,000 U. POIIOYF11LCO r 5 AUrOMO!NELIAPI11IY NNMTO CO.UIINEDOIROL.e LIMIT (Sircuany ALL OVVNFDAV109 BODILYIINURYtP HAron) S EC HE BOLES AUTOS SWAY ROW (Po Ild4IMJ 7 NULEDAUrOS PROPEIATYOAUO6 (PHlcdfsN) i NCH•017HLOAVIO9 S L A )( VMOREDIA TIM X occult 1iCC0009209 104/01/2012 04/01/20lA cuoomanaxcE _s15,000,000 OXCEIIILAB X CLVAlGVADa ACOME0/410 715,000,000 DECUCTIHE $ RETENTION I $ a WOIRIlta cOMPENUMOH AHD ENPLOYtfs'LIAEItITY SP4049886 )4101/201204/011201 Jag] Ra a�� nog DICCpEO s0lOoFFsotorcurnsl l WA E.b OMIIACCIOOLI 71 000 0 0 0 I(Mnd•Ic'sIIM L�^�� Oscan Coverage El. DISEASE, PA EMPtOYEF 71,000,000 0i74NprlouoFOPtMRJ11s CAN PL 019PA9e• POLICYLAIR 71,000,000 ORION? MOH OF OPE RUMS IO✓AJION$/ KIIICLE' Mich ACORO Wi, Weans' Monti 309(4144 II Dull 9os I, audio) Health Professional Liability • Persons Included (I/ applloablot; Profos9l)nel employees of the named Insured, other than physlctnns (See Attached Desarlpilons) CERTIFICATE HOLDER 'Credenlinling ln(ormallon Only Poudrp Valley Health Cara, Inc. Pon COlllns, CO 80828 CCCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES De CANCELLEO BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL Be DELIVERED IN ACCCRDANOe WAIT TIIE POLICY PROVISIONS, AU7HONEID NPAeseNrADVs 01088.2000 AC ORD CORPORATION, All rights reserved, ACORD 25 (2009100) 1 of 2 The ACORD name and logo are militated marks of ACORD 95694902/M884901 NIK DESCRIPTIONS (Continued from Page 1) Professional students of the named Insured, other than residents Volunteers of the Homed Insured, other than phystalaas and residents AM3 75.5 (2000(40) 2 of 2 MS6540021A15o4901 Brown a Drown Ina 4632 Boardwalk Dr, Sulla 200 Fort Collins, CO 80628 17161,870-484-1184 Tyytler D. Allen !yc n.,S70 484-1186 1 D i elf COSH 14243 See tee Brame It PVHEA•1 INSURED poudre Valley Hoolth Cara Ina ACCIRO) OP ID: JD EVIDENCE OF PROPERTY INSURANCE PA06/1412012 /2012 THIS EVIDENCE OP PROPERTY INSURANCE IS ISSUED AS A MATTER OP INFORMATION ONLY AND COME NO RIGHTS UPON THE ADDITIONAL INTEREST NAMED BELOW, THIS EVIDENCE OF PROPERTY INSURANCE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, £051101 ,,,,,870-082.7947 COMPANY Great Northern Insurance Co. 16 Mountain View Road Warren, NJ 07069 2316 E. Harmony Rd„ Sulfa 200 Fort Collins, CO 40628.8420 PROPERTY INFORMATION tCGATIONMESCRIPEOR tent Ne4fEA POUOYNVMeIR 6083406 El IOWA DATA al?IMnQN DATE 08/01112 06/01/19 mISAEPIAC W PAIOAEMDENOE DA fIO, COIITINVEDUiIfL nTERIFlIIATEOWCNECXED Pot Schedule of locallons on (lie THE POLICIES OF INSURANCE LISTED BELOW PAVE BEEN ISSUED TO THE INSURE° NAMED ABOVE FOR THE POLICY PERIOD INOICATED. NOTWITHSTANDING AM' REQUIREMENT, TERM OR CONDITION OF MY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS EVIDENCE OF PROPERTY INSURANCE MAY OE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED DY THE FOLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS ANDCONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE SEEN REDUCED BY PAID CLAIMS. COVERAOB INFORMATION COVERAGE IPIRILSIIORW Blanket SolidInm DPP ISp,clal Form/Ropl Cal L08B LIMIT SAFE AMOUNTOIINEUMNc1 660000000 Inoluded OIDUCDALE 23,000. 24, EAIARKS (IR01udhig Special Condlllane) CANCELLATION SHOULD ANY OF WE ABOVE DESCRIBED POLICIES RE CANCELLED BEFORE TIM EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE ADDITIONAL INTEREST NAMED BELOW, DOT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSe NO OBLIGATION OR LIABILITY OF ANY KIND UPON T11G INSURER, ITS AGENTS OR REPRESENTATIVES. ADDITIONAL INTEREST IIAMIAMDADURES1 r---, Poudre Valley Health Syetome 2316 E. Hormany Rd„ Sub 200 Fort Collins, CO 00629 MOB rOAOEE LOSS PAYEE tONI ADD11@NL INSURED AU moAUEDRrPAEnEMA Eye Wie r.4-\ ACORD 27 (2004107) ID AGGRO CORPORATION 1003.2000, All rights reserved. Tho ACORD name and logo aro registered marks of ACORD eat/ CERTIFICATE OF LIABILITY INSURANCE OP JD �. / DATE cmitoo YYY) 05/14/12 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND 7HE CERTIFICATE HOLDER. IMPORTANT: I( the certificate holder is an ADDITIONAL INSURED, the pollcy(Fes) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In Ileu of such endorsement(aL PRODUCER Thrown & Brown Inc 4532 Boardwalk Dr, Suite 200 Fort Collins CO 80525 Phone:970-482-7747 Fax:970-484-4165 Lit R IA41 NAMD A10 NA, Ert): I jNC, NG): AOOPEnS: PRODUCER CUSTOMER ID I: PVIiEA-1 INSURERtS) AFFORDINGCOVERAOE NAICR INSURED INSURER A: Travelers Casualty andSurety19038 oudre Valley Health Care Inc 315 E. Harmon Rdy,t Suite 200 Fort Collins CO 80528-8620 INSURER B: Zurich Auartca. Insurance Co _165_35 70815 _ DISURER C: The Westford IAN L Accident INSURER 0: INSURER E INSURERF: HER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POI ICY PE RICO INDICATED. NOIVTHSTANDINO NW REOUIREM NT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT MINN ESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. TILE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALE THE TERMS, EXCLUSIONS MID CONDITIONS OF SUCH PODGIER. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAIDCLA!MS BISR h R TYPE OF INSURANCE ACM MR RUSK WVD POLICY NUMBER (�LFfF�� IMMIOD IYrrY) pt, E8 MIW Y P I BOryfY) UNITS GENERAL LIABILITY EACH OCCURRENCE -PREMIat 5 COMMERCIAL GENERAL LIARLI TY ICI HEN)ED REMISES $ (Ea occurrence) CLVMS-MADE I I OCCUR MED EXP(Any are S FODOR) --- PEP:50NAL 8 ADV INJURY 5 GENERAL AGGREGATE S GENL AGGREGATE LIMIT APPLIES PER. PRODUCTSCOLIPpPAGG -"�-'-' $ POLICY I L(X: (1 S B AUTOMOBILE LIABILITY ANY AUTO BAP947490301 05/01/12 COMBINED SINGLE LIMIT !Etaroden0 $1,000,000 X ALL OWNED AUTOS 05/01/17 BCENLV INJURY (Per pNStn) S SCIIEOOL ED AUTOS BOCnIY INJURY (Per e w een0 X H RED AUTOS PACHERI'/ DAMAGE (Per accidem) 5 $ X NONO'NNEO AUTOS Comp $ $500 Ded X Auto PD EAP947490301 05/01/12 05/01/12 Coil 5$500 Ded UMBRELLA LIAR EXCESS LIAR OCCUR EACH OCCURRENCE S CLUMS•MAOE AGGREGATE S DEDUCTIBLE 5 RETENTION 5 WORKERS COMPENSATION AND EMPLOYERS' LmBILITY YIN WOSTATU. OTH- I TORY LIMITS I I III S MN PPOPRIETORIPARINERIEXECUTIV OF ICFRi1JEMBER EXCLUDED') I NIA EL. �CIIACCIORJT - 5 (Mandatory In NH) IIyes. dlSUaewale! E L. DISEASE. EA EMPLOYEE - S DESCRIPTION OF OPERATIONS Ce'p.Y E L 'ASEASE- POLICY LIMIT S A C Crime Volunteer Accident 104900205 34SR845295 03/10/10 01/01/11 03/10/13 07/01/12 Empl Dish $250,000 Medical $10,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES Plea ACORD lot, AddIII,nsl Remerki Schedule, It mare Spate In required) For info only eronnra ye tine ....,. PVHHEAL Poudre Valley Health Systems 2315 E. Harmony Rd 4200 Ft. Collins CO 80528 SHOULD ANT OF THE ABOVE DESCRIBEDPOLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THE REOF,NOTCE WILL RE DEL NERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPRESENTATIVE ,,W,,\\a ACORD 25 (2009109) .2009 ACO CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Client/1; 12532 PVHEA ACORE"tl, CERTIFICATE OF LIADILP Y INSURANCEDr/o�izotz w� THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AFFIRMATIVELY ON NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A COIITRACT BETWEEN 'DIE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: II the cedlllcale holder Is an ADDITIONAL. INSURED, the po0ry(les) must he endorsed. II SUBROGATION IS WAIVED, sah)ecl to (ho terms and condllloas of the policy, certain policies niny require an endorsement. A stalemont on tilt cellllkele does not confer tights to the cedillcolo holder In Ilan of such Didorsemonl(s). PRODUCER Flood & Paterson Ins., Inc. P. O, flax 570 Graefoy, CO 80632 070 366.0123 . IODISED Powlre Valley Ilea11li Care, Inc. die Poadre Valley Health System 2315 E Harmony Road, Salle 200 Foil Collins, CO 00528-0620 rnnrkcY NADE Nikki Moshruckor "lit ___.070266.7123 r,Lx oime, can; I IArC, Uei: 070 506-6823 s .mOsbNtker@floodandpolerson.com t cannons III e: I!ILLXIEII(t) AFFORO!IIO COVERAGE ) IIAca INSURER A: Coplc Companies mirth; e: Safety National Casually Compan IlISIlRER C; e1SUnER R; IIICURER E ; USURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THISTS.TA CERTIFY THAT 111E POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO HIE INSURED NAMED ABOVE FOR Vic POLIICVPENI00 INDICATED. NOTVJITIISTAMOINO ANY RECUIRELIENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER OOC WENT WIIH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, TIIE INSURANCE AFFOROED DY THE POLICIES DESC ISIS EC) HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONOIUONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BV PAID CLAIMS iASrt TYv& OF INSURANCE ',� �OLICy�--p Q'fO rrEXF POLICY MAIM I'AIVDOrypI IAAVOOM'YV� HCC0008522 14/01/2012 0410112013 RENERAI LIABILNY > COHMERCIAI GECER�AI SWAIN CIAIAISAIADE LAI OCCUN X Malpractice Llabllli 1y GENT AOOREOATE t I111r APPLIE3 PER: PRO tor. UTOMOBILE LIABILITY Al YAU10 11 OYDIEDAUTOS ClIEOULED AUtOs HMCOAUTOS II(1Il-ONNED AUTOS YAeREL LA LIAO ccc UR EXCESS LIMY X CLAISISMAOE DFDUCIDLE ENT b 1 WORKERS COMPENSAIIOU MID EMPLOYERS' MOIL HY OFFICEIEAEUUKLH EEACWCED)kL'UINf N (M an dalmy In 1118 DESCNIPIIIDDIO Vales aeon WA Rolm Palo: 5/1/1004 IICC0000203 /SPA0438N Excess Coverage (IIA115 EACH OCCIIRREIYE DAME TO REDTEO PREMISES IFScast:ma:,l LIED ESPJAMS as person) PERSOIIAL d AOVIIIIURY CRIFRALAOOREOAIE $1,000,000 s500 000 $51000 11,000,000 $3,000 000 s1,000,000 PM/SIDED S THOLE Li Dm (Ea alddlnl) BODILY INJURY IPt, Omen) BODILY IIIIUNY Wei ie61en]) PROPERTYDR.WUE (P.OWAn1) a S $ $ $ $ 000112012 O4/O1/2013' EACHCCCUMu10E 4/01/2012 ADORE GATE 01/0112013. X TOR $ P.S. EACHACCmERt s1 000 000 El. DISEASE. EAEIIPLOYEE $11000,000 E t. DISEASE - PDLICYIIttII 51,000,000 DE.SCRIYIIDN of OPERALOII I LOCAIIOIIS / VEHICLES (Anse] ACOHo let,Add:llo,cel Remake GHGdul., Drama spate h,egWnJ) CERTIFICATE HOMER CANCELLATION Sample Certificate SHOULD Al1Y OF TIIE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE DIE EXPIRATION DATE THEREOF. 110 'ICE WILL OF DELIVERED III ACCORDANCE WITH TIIE POLICYPROVISIOIIS, AUIIIODIE ED REPRESEOTATIVe 1 I lJ P�I�L�GT"IYIULL.l1,1.J1,Qr7aLA/» I $01080-2000 ACORD CORPORATION. All dards reserved. ACORD 25 (2000/03) 1 of _I Ilia ACORD Damp end logo are re ()Island marks ni ACORD DS714208/M684001 DXS ttI ere ZURICH COMMERCIAL INSURANCE Policy Number BAP 9474903-01 Named Insured and Walling Address POUDRE VALLEY HEALTH CARE INC (SEE NAMED INSURED ENDT) 2315 E. HARMONY RD STE 200 FORT COLLINS CO 80520 COMMON POLICY DECLARATIONS Renewal of Number BAP 9474903-00 Producer and Walling Address THOMPSON JRANCE MEADO{ STPKWYJI ENTERPRISES STE 100 KENNESAW GA 30144-5881 Producer Code 01087-000 Polley Period: Coverage begins 05-01-2012 at 12:01 A.M.; Coverage ends 05-01-2013 The name Insured Is (] Individual O Partnership fD Corporation ❑ Olher: This Insurance is provided by one or mare of the stock Insurance companies which are members of II}a Zurich-Asnertean Insurance Group. 'ma company that r tprovides Menne is his policy as'T a Company', we. or Coveragelddress or the col➢rlels of foe)e Zurichl'enarican Insurancese Goupl are proIhis vided on Ise urance next be e. bin THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE(S): �~ BUSINESS AUTOMOBILE issued by ZURICH PAERICAN INSURANCE COMPANY THIS PREMIUM MAY BE SUBJECT TO AUDIT. This premium does not include Taxes and Surcharges. at 12:01 A.W. PREMIUM S 110,297,00 Taxes and Surcharges The Form(s) and Endorsenwni(s) made a part of this policy al the lime of issue are listed on the SCHEDULE of FORMS and ENDORSEMENTS. Countersigned this clay of 110,297.00 TOT/4. S TOTAL S Aolncrized aepreeenlElvl THESE DECLARATIONS TOGEBIFft WITH WE COMMON POLICYCONDITIONS, COVERAGE PART DECLARATIONS, COVERAGE PART FORM(S). FORMS AND FNDORSEMEIrTS, IF ANY. ISSUED TO FORM A PART THEREOF, COMPLETE WE AnOVE NUMBERED POLICY. U.Gli.0.310A 101,' 93) Page ... n! . Pollcy Number OAP 3474903-01 SCI IEDIIIE OF FORMS AND ENDORSEMENTS ZURICH AMERICAN INSURANCE COMPANY Named Insured p0UDRE VALLEY HEALTH CARE INC ApenlName THOMPSON INSURANCE ENTERPRISES COMMON POLICY FORI•IS AND ENDORSEMENTS U -GU -D -310-A U -GU -619-A CW U -GU -319-F U -GU -G21 -A CW IL 00 17 IL 00 21 IL_0.1 69 IL 02 28 IL 00 03 L-((ecliWe Dale: 05-01-12 12:01 AM., Standard Tint Agent No. 01087-000 01-93 001411ON POLICY DECLARATIONS 10-02 SCHEDULE OF FORMS AND ENDORSEMENTS 01-09 IMPORTANT NOTICE - IN WITNESS CLAUSE 10-02 SCHEDULE OF NAMED INSURED(S) 11-98 COMMON POLICY CONDITIONS 09-08 NUCLEAR ENERGY LIABILITY EXCLUSION ENDT 09-07 _..Co CHANGES-CONC4ALMENT,..MTSRDD,._OR FRAUD 09-07 COLORADO CHANGES-CANC & NONRENEWAL 09-08 CALCULATION OF PREMIUM AUTOMOBILE FORMS AND ENDORSEMENTS CA 20 54 CA 23 84 CA 23 94 U -CA -Ill -C CW U -CA -548--A CW U -CA -D -600B CA 00 01 CA 01 13 CA 20 99 CA 21 50 CA 24 02 U -CA -816-A CW CA 20 02 CA 20 18 CA 20 48 CA 99 28 CA9960 10-01 EMPLOYEE HIRED AUTOS 01-06 EXCLUSION OF TERRORISM 03-06 SILICA/SILICA-RELATED EXCL FOR COVRD AU 01-09 PREMIUM AND REPORTS AGREEMENT COMPOSITE 10-06 SCHEDULE OF AUTO PHYSICAL DAMAGE DEDUCTI 06-10 BUSINESS AUTO DECLARATIONS 03-10 BUSINESS AUTO COVERAGE FORM 01-11 COLORADO CHANGES 03-10 CO E14RG VEHCL VOL FIREFGHTRS/FIRERS EXCLD 01-11 CO UM COVERAGE - BODILY INJURY 12--93 PUBLIC TRANSPORTATION AUTOS 03-10 AMENDMENT OF DECLARATIONS - ITEM 4 03-10 SOUND RECEIVING EQUIP COVG -FIRE, POLICE 12-93 PROFESSIONAL SERVICES NOT COVERED 02-99 DESIGNATED INSURED 03-10 STATED AMOUNT INSURANCE 03-10 AUDIO, VISUAL AND DATA ELECTRONIC EQUIP U -G U•619 -A CW(10102) COLORADO INSURANCE IDENTIFICATION CARD COMPANY NUWEER COMPADY j'�� 16576 Zurich American Insurance Co.ERnAI L_J PERSOWI POLICY NUMBER BAP947490901 EEOW DATE EXP;RATIONDAIE 06/01/12 05/01/19 MEAD WXEA!ODEt mMICLE(DEW:CArloN NUMBER 1992 GMC Suburban 10KPK16K6NJ728454 Brown & Brown of Colorado, Inc Tyler B. Allen 4632 Boardwalk Dr, Suite 200 Fort Collins, CO 80525 INSURED r Poudro Valley Health Care Inc 2915 E. Harmony Rd., Salle 200 Fort Collins, CO 80526.8620 BI and PD Coverage Provided SEEIUPORTANT NOTICE MERV/EASE SIDE THIS CARD MUST BE KEPT IN THE INSURED VEHICLE AND PRESENTED UPON DEMAND IN CASE OF ACCIDENT; Report ell accidents to your AgenUCompany as soon as possible. Oblaln the following In(crmallore 1. Name and address of each driver, passenger and witness. 2. Name of Insurance Company and policynumber for each vehicle Involved, ACOROEs CO IIDoirail OACOAD C0MoRAl10N N1D2iDE. AB elplibi ni uriP. /td PVHEA•1 JD COLORADO INSURANCE IDENTIFICATION CARD COUAPNIY INOBER COMPARE [] COTI0ERCUI PERSONAL 16635 Zurich American Insurance Co. POLICY IN96ER EFFECTIVE GATE EXPIRATION DATE BAP947490301 06/01/12 06/01/13 YEAR *UR61.!OOEI VEHICLE IDENTIFICA7.WNNUITOTA 2003 Ford (MEDI) 1FDXE46F43HB28716 Brown &Brown ISSUING Inc Tyler B. Allen 4632 Boardwalk Dr, Suite 200 Fort Collins, CO 80526 nuueen r Poudre Valley Health Care Inc 2316 E. Harmony Rd., Suite 200 LFort Collins, CO 80628.8620 Di and PD Coverage Provided SEE IMPCRTANE NOTICE CIIRET/ERSE EIDE THIS CARD MUST BE KEPT IN THE INSURED VEHICLE AND PRESENTED UPON DEMAND IN CASE OF ACCIDENT: Report all accidents to your Agent/Company as soon as possible. Obtain the following Information: 1. Name and address of each driver, passenger and witness, 2. Name of Insurance Company and policy number for each veh(Ge Involved. ACORO ID 00n1271nJ oAcORD CORPORA71DR 2001.100• All eaau n.w.E. PVHEAC JO COLORADO INSURANCE IDENTIFICATION CARD CV/PRIVRUSI3ER COUPNm O COME RCIAt n PERSONAL 16635 Zurich American Insurance Co. PIXICYINMeER EFFECTIVE DATE EtFIRATICNDAIE BAP94T490301 05/01/12 05,01/13 YEAR M KE:MODEL 2006 Ford 1EMS2J /21 L. • AGENCY/COMPANY ISSUING CARD Brown & Brown of Colorado, Inc Tyler B. Allen 4532 Boardwalk Dr, Suite 200 Fort Collins, CO 80526 INSURED Poudre Valley Health Care Inc 2315 E. Harmony Rd., Suite 200 Fort Collins, CO 80528.8620 L VEH DIE IDENTIFICATION NUMBER 1FDSS34P96HB20607 BI and PD Coverage Provided SEE IMPORTANT NOTICE ON REVERSE Slot THIS CARD MUST BE KEPT IN THE INSURED VEHICLE AND PRESENTED UPON DEMAND IN CASE OF ACCIDENT: Repod all accidents to your Agent/Company as soon as possible. Obtain the following Information: 1. Name and address of each driver, passenger and witness. 2. Name of Insurance Company and policy number for each vehicle Involved. ACOaD II CO 601/04 OACOPPCOMOMROA BObNO,. AI FRIO tutr,P. M7/ PVHEA-1 JO PVHEA•1 JD COLORADO INSURANCE IDENTIFICATION CARD COMPANY I:UMBER 16535 POLICY NUMBER BAP947490301 YEAR 1.'.U(E'MOCEL 2003 Ford E4501MED AO EI IGYA'OMPAIY ISSIRNO CAao Brown & Brown of Colorado, Inc Tyler B, Alton 4532 Boardwalk Dr, Sufle 200 Fort Collins, CO 80625 INSURED r COMPArY n COMMERCIAL Zurich American Insurance Co. Poudre Valley Health Care Inc 2316 E, Harmony Rd., Sulle 200 Foil Collins, CO 80528.8620 L EFFECTIVE DATE 05/01112 L -I PERSONAL LAPIMTIONUATE 05101/13 VEHICLE IOEIRIFICATIOUNUUBEa 1FOXE45FX3HA31598 * BI and PD Coverage Provided SEC IYPORINRNOOCE on REVERSE SIDE THIS CARD MUST BE KEPT IN THE INSURED VEHICLE AND PRESENTED UPON DEMAND IN CASE OF ACCIDENT: Report all accldenls to your Agent/Company as soon as possible. Obtain the following Information: 1. Name and address of each driver, passenger and v4lness, 2. Name of Insurance Company and policy number for each vehicle involved, ACORD 10 CO 12EON0E) OACOROCORPoMi1DNEBIId021. All right, ttNtlf4 COLORADO INSURANCE IDENTIFICATION CARD Coo PAI(Y HUYB ER COMPANY 16535 Zurich American PODGY HUMBER BAP947490301 YEAR MAXEAODZL 2006 Ford E450(MED 4 Brown & Brown of Colorado, Inc Tyler 8, Allen 4532 Boardwalk Dr, Suite 200 Fort Collins, CO 80525 INSURED r Feud,e Valley Health Care Inc, 2316 E. Harmony Rd., Suite 200 Fort Collins, CO 80628.8620 QconwacAE Insurance Co, Eft WINE OW 05/01/12 IDPERSO,YAE EAPIMIIDNDAIE 05/01/13 VENUE ICEIMFICAIKM NUAIDER 1FDXE46P26DA 21099 BI and Pb Coverage Provided SEE IYPORTNU RO?ICEOUREVERSE S10E THIS CARD MUST BE KEPT IN THE INSURED VEHICLE AND PRESENTED UPON DEMAND /oae So EDISON,' 0ACOMLORPURATUy 1p)<-p,p], All rights pis trvid. IN CASE OF ACCIDENT; Report all accidents to your Agent/Company as soon as possible. Obtain the fottowing Information; .1. Name and address of each driver, passenger end witness. 2. Name of Insurance Company and policy number ;or each vehicle Involved, r PVHEA-1 JD PVHEA•1 JD COLORADO INSURANCE IDENTIFICATION CARD CC MPANY NUMBER CO'APANr n COMFIERCIAI O PERSONAE 16636 Zurich American Insurance Co. POLICY RAMIE EfrEOTNE DATE EXPIRAI,ONOATE BAP941490301 05/01/12 05/01/13 YEAR MARLIIOOEL 1999 Ford MED Whaa:coo Brown &ABrown of Colorado, Inc Tyler B. Allen 4632 Boardwalk Dr, Sulfa 200 Fort Collins, CO 80625 INSURER r Poudre Valley Health Cue Inc 2315 E. Harmony Rd., Suite 200 Fort Collins, CO 80528.8620 VOICE IOEUtIFICALON$UFIBER IFDWE30F5XHA26893 Bland PD Coverage Provided SEE IMPCRTMIT NONCE IMMERSE SIDE THIS CARD MUST pE KEPT 1N THE INSURED VEHICLE AND PRESENTED UPON DEMAND IN CASE OF ACCIDENT: Report all accidents to your AgenVCompany as soon as possible, Obtain the following Informallon: 1. Name and address of each driver, passenger and witness. 2. Name of Insurance Company and policy number fcr each vehicle Involved. AC ORO IS CO (20071035 OACCAO CORPOMnoN BDOGi*or, Al rights non,R. COLORADO INSURANCE IDENTIFICATION CARD LO.RRAIiNNUMBER CCCIPAIB I ICOSIMEAHAL n pERSOWI 16636 Zurich American Insurance Co. POUCYIIUx BER Eff(CENE OATS EAPIEDOIONDAM 8AP947490301 05/01/12 06/01/13 YEAR MAKEMOD°t VEHICLE IOEIflICATICNjVMREa 2006 Ford E450 1FDXE45P86HA16380 Brown & Bro vn of Colorado, Inc Tyler B. Allen 4632 Boardwalk Dr, Suite 200 Fort Collins, CO 80526 INSURED r Poudre Valley Health Cara Inc 2315 E. Harmony Rd., Suite 200 Fort Collins, Co 80628.6620 L SI and PD Coverage Provided SEE II/PORTANT NOTICE ONREVERSE SIDS This CARD MUST BE KEPT IN THE INSURED VEHICLE AND PRESENTED UPON DEMAND IN CASE OF ACCIDENT; Report all accldonis to your Agent/Company as soon as possible. Obtain rho following Information: 1, Name and address of each driver, passenger and witness. 2. Name of Insurance Company and policy number for each vehicle Involved. ACORO it COIEP011011 oAcoRncouoRATIOH feuet)1..Ul Nanu comae. m 4/ PVHEA-1 JD PVHEA.1 JD COLORADO INSURANCE IDENTIFICATION CARD COMPANY NUMBER COMPANY X' COMNIERCRI El PERSONAL 18635 Zurich American Insurance co. POEWY NUMBER EFFECTIVE DATE EXPIRATIONDATE BAP947490301 06101/12 06/01113 YEAR VAKEALODEL 2008 Ford F360 AOENCYICOMPA11Y ISSUING CND Brown & Brown of Colorado, Inc Tyler B. Allen 4632 Boardwalk Or, Suite 200 Fort Collins, CO 80626 INSURED r VEHICLE IDENTIFICATION WAVER 1FDWF36R38E825617 Poudre Valley Health Care Inc 2315 E. Harmony Rd., Suite 200 E Fort Collins, CO 80528.8820 Al end PO Coverago Provided SEE IMPORTANT NOTICE ON REVERIE SIDE THIS CARD MUST DE KEPT IN THE INSURED VEHICLE AND PRESENTED UPON DEMAND IN CASE OF ACCIDENT: Report all accidents to your AgonUCompany as soon as possible. Obtain the following Information: 1. Name and address of each driver, passenger and witness. 2. Name of Insurance Company and policy number for each vehicle Involved. ACORD IS Co (20071 14 CAcofo CORPORATION roel.toor. All Aphis min. e. / COLORADO INSURANCE IDENTIFICATION CARD COMPANY NUMBER COMPANY 16536 Zurich American InsuranceCOMMERCIAL Co.DDEi PERSONAL PClI0( NUMBER EFFECTIVE DALE ERPIRATI0N0ATE BAP94749D301 05/01/12 05!01/13 YEAR MAREMODSI VEHICLE IDEMNICATIOYNUMBEH 2008 Ford F350 1FDWF36R58EB25618 AOENCY.COMPANY MONO CARD Brown & Brown o1 Colorado, Inc Tyler B. Allen 4532 Boardwalk Dr, Suite 200 Fort Collins, CO 80526 INSURED Poudre Valley Health Caro Inc 2316 E. Harmony Rd„ Sulle 200 Fort Collins, CO 80528.8820 L BI and PD Coverage Provided SEE NP0RrAMN3TKE O21REVZR5E SIDE THIS CARD MUST DE KEPT IN THE INSURED VEHICLE AND PRESENTED UPON DEMAND IN CASE OF ACCIDENT: Report all accldenls to your Agent/Company es soon as possible. Obtain the following Information: 1. Name and address of each driver, passenger and Witness. 2. Name of Insurance Company and policy number for each vehicle Involved. OAC0RD C0RP0MTI01110E1.r0)7. All rights nume, Ati PVHEA-1 Jo PVHEA•1 JO COLORADO INSURANCE IDENTIFICATION CARD COUPATY NUMBER 16535 POLICYAVNBER BAP947400301 YEAR MAREM00ZL 2008 Ford F38a Brown &Brown of Colorado, Inc Tyler B. Allen 4532 Boardwalk Dr, Suite 200 Fort Collins, CO 80626 INSURED r Poudre Valley Health Care Inc 2315 E. Harmony Rd., Salle 200 LForl Collins, CO 80628.8620 COMPANY COMUEROAL DPERSONAt Zurich American Insurance Co, EFFECTIVE DATE EEPIRA71080ATE 05/01/12 05/01113 YEN DIE IDENTIFICATION WIDER 1FDWF36R78EB 25610 BI and PD Coverage Provided SEE IMPORTANT IIOTICE ONREVERSE SIDE THIS CARD MUST BE KEPT IN THE INSURED VEHICLE AND PRESENTED UPON DEMAND IN CASE OF ACCIDENT; Report all accidents to your Agent/Company as socn as possible. Obtain the following Information: 1. Name and address of each driver, passenger and witness. 2. Name al Insurance Ccmpany and policy number for each vehicle Involved. mow, so Co pose)) 0scow CDPYOMTIDN IGII-KSY. All donu n+mro. /17/3- YEAR MARE ICOEA 2008 Ford F360 2wd AGENCY/COMPANY rown R Brown of Colorado, Inc Tyler B. Allen 4632 Boardwalk Dr, Suite 200 Fort Collins, CO 80525 ads USED r Poudre Valley Health Care Inc 2315 E. Harmony Rd., Suite 200 Fort Collins, CO80528.8820 COLORADO INSURANCE IDENTIFICATION CARD COMPMrr MAWER CO 'MANY O COAWERCNA I I PERSO.YAL 16635 Zurich American Insurance Co. POW:MAWR EFAECTNE CA11 EAPIMTIQROST! BAP947490301 05/01112 06101/13 VEHICLE Miff if DER SFDWF36R66ED13130 BI and PD Coverage Provided see IMPORTANT NOTICE QRRSVERSE SIDE THIS CARD MUST BE KEPT IN THE INSURED VEHICLE AND PRESENTED UPON DEMAND IN CASE OF ACCIDENT: Repel all accidents to your Agent/Company as soon as possible. Obtain the Iollovdng Information; 1. Name and address of each driver, passenger and wllness, 2. Name of Insurance Company and policy number fcr each vehicle Involved. ACORO 10 CO Wont.); OAGOAO COMOMTOII:!{Flee). M e9lq Min". PVHEA•1 JD PVHEA•1 JD COLORADO INSURANCE IDENTIFICATION CARD CCMPANY NUMBER 16636 PaICYNWMER BAP947490301 Y&n AtAXERAODSL 2008 Ford F3502wd AOEROY.CONPNEYIS UM CARO Brown & Brown of Colorado, Inc Tyler B. Allen 4532 Boardwalk Dr, Sulle 200 Fort Collins, CO 80625 INSURED r Poudre Valley Health Care Inc 2318 E. Harmony Rd., Suite 200 Fort Collins, CO 80528.8620 COMPANY n COSRIERCAt Zurich American Insurance Co. EFEEGTIVEMiE EYPoMTIONDATE 05/01/12 06101/13 VENCtE IDEInIFICA1lON 1N5lo ER 1 FDWF36RX8ED13129 BI and PD Coverage Provided SEE RIPOR Wll NOTICE Cu REVERE E 810E F-1 SCAT THIS CARD MUST BE KEPT IN THE INSURED VEHICLE AND PRESENTED UPON DEMAND IN CASE CF ACCIDENT: Report all accidents lo your Agent/Company as soon as possible. Obtain the follotdng Information: 1. Name and address of each driver, passenger and witness. 2. Name of Insurance Company and pcllcy number for each vehicle Involved. AGORD IO CO neo1INI OAG0RDCDRP0MTI0IE NIFNIr. AIltlrPD mind. COLORADO INSURANCE IDENTIFICATION CARD COIEANY Nova E1 MAMMY n GOMMERC(I UPE RSODA1 16535 Zurich American Insurance Co. ROME NUMOER EFFECTA?EDATE ENAM71011 DATE 8AP947490301 05/01112 05/01(13 YEAR - A'ARr,MODEE 2008 Ford SupCab4 Brown & Brown of Colorado, Inc Tyler 8. Alien 4532 Boardwalk Dr, Sulfa 200 Fort Collins, CO 80525 mSURED r Poudro Valley Health Caro Inc 2315 E. Harmony Rd., Suite 200 For( Collins, CO 83528.8620 VEHICLE IDENnrICATWHNUNOER 1FDWX37R38ED13131 BI and PO Coverage Provided SEE MIMI TNR 1(0710E ON REVERSE SIDS THIS CARD MUST BE KEPT IN THE INSURED VEHICLE AND PRESENTED UPON DEMAND IN CASE OF ACCIDENT: Report all accidents lo your Agent/Company as soon as possible. Obtain the following Inform alien: 1. Name and address of each delver, passenger and witness, 2. Name of Insurance Company and policy number for each vehicle Involved. ACOAO I! Co WOW)) OAC0RC COMOMTICAE00DO001. AO COIF NO rod. PVHEA.1 JD PVHEA.1 JD COLORADO INSURANCE IDENTIFICATION CARD COMPANY KHMER COMPANY n COMMERCIAL O PERSONAL 16536 Zurich American Insurance Co. POLICY NVMSER EFFECTIVE GATE EXPIRATIONDATE BAP947490301 05/01/12 05101/13 YEAR MA(E,TOOFI VEHICLE IC 9ntFICAf10N NVABER 2009 Ford F3s0 1FDV/F36R4SEA60827 AGEUGYICOMPAlft I$5 WHO CARO Brown & Brown of Colorado, Inc Tyler B. Allen 4632 Boardwalk 0r, Suite 20D Fort Collins, CO 80525 INSURED r Poncho Valley Health Care Inc 2316 E, Harmony Rd., Suite 200 Fort Collins, CO 80528.8820 BI and PD Coverage Provided 9EE IMP0RFAR NOTICE CLARE VENSE SIDE THIS CARD MUST BE KEPT IN THE INSURED VEHICLE AND PRESENTED UPON DEMAND IN CASE OF ACCIDENT: Report all accidents to your AgenVCompany as soon as possible. Obtain the following Informalion: 1. Namo and address of each driver, passenger and witness. 2. Name of Insurance Company and policy number for each vehicle Involved, ACORO SO COMMON OACORO CORPORATION NEbI1Ob All dTh', mimed. di /1 COLORADO INSURANCE IDENTIFICATION CARD CO.MPNIE RIMER [WPM( n COMMfRVAt nPERS0NAL 18535 Zurich Amorican Insurance Co. PCIICY ?WEER EFFECINE DATE EXP AIIOe DATE BAP947490301 06/01/12 05/01113 YEAR MAKE:YODEL 2010 Ford F-15 Brown & Brown of Colorado, Inc Tyler B. Allen 4632 Boardwalk Dr, Stolle 200 Fort Collins, CO 80526 INSURED r Poudre Valley Health Care Inc 2316 E. Harmony Rd., Sulfa 200 LFort Collins, CO 80528.8620 BI and PD Coverage Provided SEE IMPORTANT NOTICE 0!I REWIISr SIDE VEIIICEE IDEIneICAr10NNURDER IFDAF4HRVAEA90177 THIS CARD MUST BE KEPT IN THE INSURED VEHICLE AND PRESENTED UPON DEMAND IN CASE OF ACCIDENT: Report all accidents to your Agent/Company as soon as possible. Obtain the following Information: 1. Warne and address of each driver, passenger and wllness. 2. Name of Insurance Company and policy number for each vehicle Involved. AGSM) C0CO DO PIM) OAeoae CORPORATION nroeow. ARdrnu mimed, PVIIEA•1 JD PVHEA.1 JD COLORADO INSURANCE IDENTIFICATION CARD COMPNIYNUVBER COMPANY COMSIERC'AL n PERSONAL 16635 Zurich American Insurance Co. POLICY NUMBER EFFECTIVE DATE BAP$47490301 EDATE 05/01/12 05/01/1 OS/01H3 YEAR MARLMC Del 2010 Ford Hasler AGSMs/COMM ISSUING CARD Brown & Brown of Colorado, Inc Tyler B, Allen 4632 Boardwalk Dr, Suits 200 Fort Collins, CO 80526 INSURED P Poudre Valley Health Care Ino 2315 E. Harmony Rd., SIII{e 200 `Fort Collins, CO 80528.8820 VEHICLE IDEFIN6 CA? ION NUMB ER 1FDWF3GR3AEB38114 SI and PD Coverage Provided SEE IMPORyNn NOTICE ONREVERSE SIDE THIS CARD MUST BE KEPT IN THE INSURED VEHICLE AND PRESENTED UPON DEMAND IN CASE OF ACCIDENT: Report all accidents to your Agenl/Company as soon as possible. Obtain the following Information: 1. Name and address of each driver, passenger and witness. 2. Name of Insurance Company and policy number (or each vehicle Involved. ACOM10 C0{1001103) OACORO CORPORATION 20.14.101. All dg ON NIIN,A. LI COLORADO INSURANCE IDENTIFICATION CARD CO.PAN/NUMBER COMPANY ri 16535 Zurich American Insurance Co.AEgLIAI �pfPSOUtt PIXILY AL!AB.R E PECIIVY DATE EXPlamtalt DATE RAP947490301 05/01/12 05101113 VIM mAREAICIO VEICCIE IO;NTIrILAn011 NURSER 2011 Dodge Ram360 3D6WF4EL%13O674309 ACIEMBrown &EBroown of Colorado, Inc Tyler B. Allen 4532 Boardwalk Dr, Suite 200 Fort Collins, CO 80526 DISCOED r Poudre Valley Health Care Inc 2315 E. Harmony Rd., Sulto 200 Foil Collins, CO 80528-8620 L DI and PD Coverage Provided SEE IMPOR1Rn NOTICE DNREVERSE S OE THIS CARD MUST BE KEPT IN THE INSURED VEHICLE AND PRESENTED UPON DEMAND IN CASE OF ACCIDENT, Report at accldenis to your Agent/Company as soon as possible. Obtain Iha following Informallon: 1. Name and address of each driver, passenger and wllness. 2. Name of Insurance Company and policy number for each vehicle Involved. ACORC IB Co 4207,011 CACORO CORPORATION MAIM. All REnh, „„„,a. IV] 2 - PVHEA.1 JD PVHEA•1 LD COLORADO INSURANCE IDENTIFICATION CARD COMPANY NUMBER I COMPANY I COMMERCIAL n PERSONAL 18636 Zurich American Insurance Co. PCEICY NUMBER EFFECTIVE VALE EXPI RAMION GATE DAP94749O3O1 06/01/12 06101/13 YEAR KW/MODEL 2012 Mercedes Ambulanc AOINCY/COMPANY ISSUING CAR O Brown & Drown of Colorado, Inc Tyler B. Allen 4632 Boardwalk Dr, Suite 20D Fort Collins, CO 80626 emu ti ED r Poudre Valley Health Care Inc 2316 E. Harmony Rd., Sulle 200 I. Collins, CO 80628-8620 VEHICLE lOSrnlFICATION IIUMeEn W 8PF3CC9C9604702 BI and PO Coverage Provided SEE VAP0RTMT NOTICE ON REVERSE SIDE THIS CARD MUST BE KEPT IN THE INSURED • VEHICLE AND PRESENTED UPON DEMAND IN CASE OF ACCIDENT: Report all accidents to your AgengCompany as soon as possible. oblain the following Information: I. Name and address of each driver, passenger and witness, 2. Name of Insurance Company and p ollcy number for each vehicle involved. ACORN r4 coupons,' YA50R0 COAPOMIIODI2044100?. All lights II um d. POD DRE VALLEY HEALTH SYSTEM Pounce Valley Hospital Ambulance Service Medications Required by Protocol __ Acetylsalicylic Acid (Aspirin) Adenosine (Adenocnrd) Albuterol Albnterol /lpraropionrfuoNel Alniodaronc Atropine Calcium Chloride __ Dextrose 50% Diphenbydrmnino(Ficnadryl) _Dopamine (Intropin) Epinephrine (Adrenaline) I:10,000 Epinephrine (Adrenaline) 1:1,000 Itentanyl (Sublininzc) Puroselnide (Lasix) Gluengen Glucose (15) _ Lidoceine (Xyloenine) _ Lorarepum (Ativan) Magnesium Sulfate Mannitol Melbyprednisolonc (Solo-Medrml) Midnzolnm (Versed) Morphine Sulfate Naloxone (Hereon) Nitroglycerin (paste and spray) Olouzapine (Lyptexa) Ondansetrou (ODT/vial) (Zolfren) Oxygen (imitable) O.xylocin (Niacin) Phenylephrine Intrrnosal Raceinic Epinephrine Sodium Bicarbonate Pcrbutnlinc _ Vesopressin (Petressin) Supervisor Rigs (EMSI and Med 18 EMS2) Atropine & Pial dos in lute (Douidote) Cyanokit l David Farstad, M.D 0uNallonai Qality Award 11/20/2012 ,t :111'" Poudlo val'oy Ilospilal i 1024 5.1.emayAvenuo • Foot Ce!(ns, Colorado 80544 • Phone. (970) 49&7345 Medical Cenler al Rockies • 7500 Way Mountain Avenue • Loveland. Coorado 80538• Phone: (970) 8244370 1'OUDR13 VALLEY HEALTH SYSTEM 11/26/12 I'VFI EMS IlLS MED LIST V _ Albuleyol Aspirin D50 Olufosc/ oral glucose 7 David Fantod, M.D. Oxygen , 12/ /2012 i0f I ; onal sly id Poudro Valley Hospital • 1024 S. temay Aeons . Fort Collis. Coloindo 80524 • Phone: no; 495.7245 7d10.'Cal Conley of Roohles • 260D Rocky Mounlen Avenuo • Loveland, Co!otedo 80S3e• Phone: Q)70) 62,1.13/0 /® ©w ■ � U3 w r� 2 0 U co oi ii 0 k j /� 2LE 2 qJi @ {2 w� \2 &2 _�0V /2k\0 x0 a2 km .3(14)§2 co a. a.� O7 13 o QE2-a a. § / C \ 2 / k § _ �§ :R2�� $w O k \ 0 I. .c a Q 2 \ 0 0 Drugs Carried in All ALS Rigs % 0 wNCON w (N' mm<Nga-«m#A@mmeCN1(� E ( . . . k a Adenosine .O 2 2 _ 4) g 7 A R co § , a c u� cn k k 9 g c.) o e e E § e u © o o S E( •2 §§ S q O_ ro g —smo ¢\ r) -....al N -© k k vo%$� " f� 3e*� « c g Q 2»» g E e g c O › c ■ _ m m to ff.s.cc $ffkkkCt%24�f&st �c0a�$ ■ 0 o o° C g.C,2 t A 8 q& E §{ 2 8@ c �M. w u. o E u mu) 2 2 o a n' §'5 2-0 p lo e 32 0_ *. Ri �k« «0Ooo0&mull-u.0._.a22222zzzo l'OUDRE VALLEY HEALTH SYSTEM PoutIre Valley Hospital Ambulance Service Medications Required by Protocol _ Acetylsalicylic Acid (Aspirin) Adenosine (Adeuocarcl) Albutcrol Albutcrol /1praropium-DuoNcb Antiodaronc Atropine Calcium Chloride Dextrose 50% Diphenhydraminc (13cnadryl) Dopamine (Intropin) Epiucpinine (Adrenaline) 1: 10,000 Epinephrine (Adrenaline) 1:1,000 Penianyl (Sublimate) Puroscmide (I.asix) Glucagon Glucose (IS) _Lidocaine (Xylocaine) Lorazepain (Myatt) Magnesium Sulfate Mmmilol Melhypeednisolone (Solt -Medrol) Midazolnm (Versed) Morphine Sullhlc Naloxone (Naram) Nilroglycerin (paste and spray) Olanzapine (Lypi exa) Ondansetron (ODT/via!) (Zolfran) Oxygen (portable) Oxytocin (Pitocin) _ _ Phenylephrine Intrmmsal Racemic Epinephrine Sodium Bicarbonate T•crbntalinc Vasopressin (Pehessin) Supervisor Rigs (E11SI and Med is EMS2) Atropine Se Pralidoxilninc (Dominic) Cyatickii David Far:stad, iM.D. 1 1/20/2012 ua iry (21U�Ify terti flWafl11 8eiVIAetal .4+,m Poudte Valley nosoilal • 10245 Lemay Avenue • Foil Collins, Colorado 80524• Phone: (070) 405.7345 Medical Center cl Rockies • 2600 Rocky Mountain Avenue • Loveland, Colorado 80535 • Phone: (9/0)624- IJ7e POUDRP VALLEY HEALTH SYSTEM 11/16/2012. Veld County Dept. O1• Public Health & Environment 1555 North It' Ave. Greeley, CO 80631 Kevin, I have attached a usable drug check off (list), for ambulance inspections; a map (and addresses) of our station locations; an updated fleet list to include date placed in service and 4x 4 capabilities. Also, for the response area from the Greeley address, it will be the attached map of a 35 mile radius (from 6906 10th SI, 80634), so that it includes areas of return: to skilled nursing facilities, rehabs etc. Thanks for all your help and patience with are getting all the info to you in the manner you require. If more info is needed please, contact me, asap. Judith A. Bratten Supervisor of EMS Operations PVH EMS 1024 S. Lemay Ave. (970)495-8019 BV.14a tonal eilt),rd Rec nra i Poudro Valley Hospital • 10245. Lemay Avenue • Fort Collins. Co:e,ado 00624 • Phone: (070) 405.7046 ?Aedleal Conte, or Rockies • 2500 Rocky ).fountain Avenue • Loveland, eclotada 10638• Phone: (0701 574.O70 AMBULANCE SURVEY REPORT Ambulance Service: Name: Poudre Valley Hospital EMS Address: 2315 E. f farmonv Rd. Suite 200 Fort Collins Colorado► Telephone: 970 495-8019 Contact: Judi Bunten Qualification: Advanced Life Support: X Basic Life Support: __ _______ -- Vehicle VIN Number: I GKFK l t6K5NJ72845.1 Make and Model: .G\!U: License Plate Number: 104UGR Odometer: Year: 1992 Date of Expiration: 5.11,3 Vehicle Number: 1 EMS Inspected by: Ambulance Representative: General Comments and/or suggestions: Date: Dale: 1 AMBULANCE SURVEY REPORT Ambulance Service: Name: Poudre Valley Hospital EMS Address: 2315 E. Harmony Rd. Suite 200 Fort Collins Colorado Telephone: 970 495-8019 Contact: Judi Bratten Qualification: Advanced Life Support: X Basic Life Support: Vehicle VIN Number: 1 FI) X 1451431 I 1128716 Make and Model: Ford License Plate Number: 091 UGR Odometer: Year: 2003 Date or Expiration: _5/23 Vehicle Number: MI:D 1 Inspected by: Date: Ambulance Representative: Date: General Comments and/or suggestions: - - 1 AMBULANCE SURVEY REPORT Ambulance Service: Name: Poudre Valley Hospital EMS Address: 2315 N. Harmony Rd. Suite 200 Fort Collins Colorado Telephone: 270495-$01) Contact: Judi Bratlen Qualification: Advanced Life Support: X Basic Life Support Vehicle VIN Number: I FDSS34P96HB20607 Make and Model: Ford Year: 2006 License Plate Number: 0R7UGR Odometer: Date of Expiration: 5/13 Vehicle Number: ivILD_2 Inspected by: Ambulance Representative: General Comments and/or suggestions: I )ate: Dale: 1 +- 1861 t -4.- s' I- rjTY G O. ..I -- _r .._S AMI3ULANCE SURVEY REPORT Ambulance Service: Name: Poudre Valley Hospital EMS Address: 2315 E. Hammy Rd. Suite 200 Fort Collins Cuiuradu Telephone: 970 495-3019 Contact: Judi Braatten Qualification: Advanced Life Support: X Basic Life Support: Vehicle VIN Number: 1 EDXE415FX3I IA31593 Make and Model: Ford License Plate Number: 092t.fGR Odometer: Yew: 2003_ Date of Expiration: _5/13_ Vehicle Number: MEl) 4 Inspected 1w: Ambulance Representative: General Comments and/or suggestions: Date: Date: AMBULANCE SURVEY REPORT Ambulance Service: �la:me: Poudre:Vailey tlmital EMS Address: 2315 E. Harmony Rd. Suite 200 Fort Collins Colorado Telephone: 970 495. U i 9 Contact Judi Britten Qualification: Advanced Life Support: X Basic Life Support _ Vehicle VIN Number: 1 FDXE45P26DA21099 Make and Model; Ford Year: 2006 License Plate Number:_ I03UGR Odometer: s _ Date of kxpiratioi is 5/13_ Vehicle Number::b1ED 6 Inspected by: _ __-- Ambulance Representative: _ General Comments and/or suggestions: Dale: Date: AMBULANCE SURVEY REPORT Ambulance Service: Name: Poudre Valley Hospital 1a4IS Address: 2315 E. Harmony Suite 200 Fort Collins Colorado Telephone: 970 495-8019 Contact: Judi l3rattett Qualification: Advanced l..ifc Support: X Basic Life Support: _ Vehicle VIN Number: I FDWE30F5X11A 26893 Make and Model: Ford Year: „1999 License ('late Number: 098UUR Date of Expiration: 5/13 Odometer: Vehicle Number: MED 9 Inspected by: Ambulance Representative: General Comments and/or suggestions: Date: Date: 1 AMBULANCE SURVEY REPORT Ambulance Service: Name: Poudre Valley Hospital EMS Address: 2315 E. harmony Rd. Suite 200 Fort Collins Colorado Telephone: 970495-8019 Contact: Judi Bratten Qualification: Advanced Life Support: X Basic I A fc Support: Vehicle VIN Number: I FDXE45P85HA 15380 Make and Model: Ford Year: 2005 License Plate Number: 090LIGR Odometer: Date of Expiration: 5113__ Vehicle Number: MED II Inspected by: I)ate: Ambulance Representative: Date: General Comments and/or suggestions: 1861 Y AMBULANCE SURVEY REPORT Ambulance Service: Name: Poudre Valley I lospital EMS Address: 2315 E. Harmony Rd. Suite 200 Port Collins Colorado Telephone: 970 495-8019 Contact: Judi l3ratten Qualification: Advanced Life Support: X Basic Life Support: _ Vehicle VIN Number: I Vt)WP36R38EI325617 Make and Model: Ford License ('late Number: 099UGR Odometer: Year: 2008 Date of Expiration: _5/13 Vehicle Number: ►MED 12 Inspected by: — — Ambulance Representative: —_ General Comments and/or suggestions: Date: Date: -- — - 1 AMBULANCE SURVEY REPORT Ambulance Service: Name: Poudre Valley Hospital EMS Address: 2315 E. Flannelly Rd. Suite 200 Fort Collins Colorado Telephone: 970 495-8019 Contact: Judi Britten Qualification: Advanced Life Suppoil: X Basic Life Support: Vehicle VIN Number: II Fl)\VF36R58EB256l3 Make and Nilotic!: Ford License Plate Number: I 00IJGR Odometer: Year: 2008 Date of Expiration: 5/13 Vehicle Number: MED 14 Inspected by: Ambulance Representative: General Comments and/or suggestions: Date: Date: 146 o P Nr-T-Y_,- AMBULANCE SURVEY REPORT r\mhulance Service: Name: Poudre Valleyjiospital EMS Address: 2315 E. Harmony Rd. Suite 200 Fort Collins Coloracio Telephone: 970 X395-8019 Contact: Judi 1.3ratten Qualification: Advanced Life Support: X Basic Life Support: Vehicle V1N Number: 1 FDWF36R78EB25G19 ►4lake and Model: Ford License Plate Number: 1f)1 UJGR Odometer: Year: 2008 Date o1' Expiration: 5/13 Vehicle Number: MEI) I5 Inspected by: _ [late: Ambulance Representative: General Comments and/or suggestions: Date: 1 Ufa _o.UNTY-J AMBULANCE SURVEY REPORT Ambulance Service: Name: Poudre Valley Hospital EMS Address: 2315 E. Harmony Rd. Suite 200 Fort Collins Colorado Telephone: 970 495.3019 Contact: Judi Bratten Qualification: Advanced Life Support: X Basic Life Support: Vehicle VIN Number: 1 FDWF36R68ED13 l30 Make and Model: l=ord License Plate Number:_093UGR Odometer: Year: 2008 Date of Expiration: 5/13 Vehicle Number: MEU 16 Inspected by: Ambulance Representative: General Comments and/or suggestions: Date: Date: AMBULANCE SURVEY REPORT Ambulance Service: Name: Poudre Valley llospital EMS Address: 2315 E. Ilarmony Rd. Suite 200 fort Collins Colorado Telephone: 97Q495-41)19 Contact: Judi 13ratten Qualification: Advanced Life Support: ;C Basic Life Support: Vehicle VIN Number: t FDWF36RX4ED13129 Make and Model: Ford License Plate Number: 0941JGR Odometer: Year: 20OYear: 200li Dale of Expiration: 5/13 Vehicle Number: MED 17 Inspected by: Ambulance Representative: General Comments and/or suggestions: Date: Date: AMBULANCE SURVEY REPORT Ambulance Service: Name: Poudre Valley I lospital EMS Address: 2315 H. Harmony Rd. Suite 200 Fort Collins Colorado Telephone : 970 495-8019 Contact: Judi 13ratten Qualikation: Advanced Life Support: X Basic I ire Support: Vehicle VIN Number: I PDWX37R38FF)I 3131 Make and Model: Ford License Plate Nutuher:_095UGR Odometer: Year: 2008 I)ate of Expiration: _S/I Vehicle Number: MFA) 18 Inspected by: Ambulance Representative: General Comments and/or suggestions: Dat.: Date: 1 AMBULANCE SURVEY REPORT Ambulance Service: Name: Poudre Valley I lospital EMS Address: 23151.Harmony Rd. Suite 200 Fort Collins Colorado Telephone: 970 495-3019 Contact: Judi 13ratten Qualification: Advanced Life Support: X Basic Life Support: _ Vehicle VIN Number: 1 FDWF 36R49[.A60827 Make and Model: Ford License Plate Number: 102UGR Odometer: Year: 2009 Date of Expiration: 5/l:I_ Vehicle Number: IVIED 19 Inspected by: Ambul►nce Representative: General Comments and/or suggestions: Date: Date: 1 AMBULANCE SURVEY REPORT Ambulance Service; Name: Poudre Valley I lospital EIS Address: 2315 E. Harmony Rd. Suite 200 Fort Collins Colorado Telephone: 970 495-8019 Contact: Judi I3rattcn Qualification: Advanced Life Support: X Basic Life Support: Vehicle VIN Number: I PDAPr11 1R7AEA90177 \•lake and Model: Ford Year; 2010 License Plate Number_089UVR_ Odometer: Date of Iixpiratior.: _5113 Vehicle Number; IvIED_20 Inspected by: Ambulance Representative: General Comments and/or suggestions: Date: Date: 1 AMBULANCE SURVEY REPORT Ambulance Service: Name: Poudre Valley Hospital EMS Address: 2315 F. Harmonv ltd. Suite 200 Fort Collins Colorado Telephone: 970 495-8019 Contact: Judi Branca Qualification: Advanced Life Support: X Basic Life Support: Vehicle VIN Number: 1FDWF3GR3AFB38114 Make and Model: Ford License Plate Number: 0961/612 Odometer: Year: 2010 Date of I'.rzpiration: 5/13 Vehicle Number: MED 21 Inspected by: Ambulance Representative: General Comments and/or suggestions: Date: Date: 1 AMBULANCE SURVEY REPORT Ambulance Service: Name: 1'oudre Val lev Hospital EIS Address: 2315 E. Harmony Rd. Suite 200 Port Collins Colorado Telephone: 970 495-8019 Contact: Judi liratten Qualification: Advanced Li le Support: X Basic Life Support: Vehicle VIN Number: 3D6Wl'4ELXl3G57Q3Q9 Make and Medd; podd e License Plate Number: 088LIGR Odometer: Year: 201 1 I)ate of Expiration: 5/13 Vehicle Number: NED 22 Inspected by: Ambulance Representative: General Comments and/or suggestions: Date: Date: AMBULANCE SURVEY REPORT Ambulance Service: Name: Poudre Valley Hospital EMS Address: 2315 E. Harmony Rd, Suite 20U Fort Collins Colorado Telephone: 970.495_8019 Contact: Judi Branco Qualification: Advanced Life Support: X Basic Mite Support: Vehicle VIN Number: WDAPF3CCXC95049041 Make and Model: Mercedes Year: 2012 License Plate Number: 1 l 6UGR Odometer: Date of Expiration: StI 3_ Vehicle Number: MEl) 23 Inspected by: Ambulance Representative: General ('omnents and/or suggestions: Date: Date: 1 o AMBULANCE SURVEY REPORT Ambulance Service: Name: I'oudre Valley Hospital EMS Address: 2315 E. Harmony Rd. Suite 200 Fort Collins Colorado Telephone: 970 495-8019 Contact: Judi t3ratten Qualification: Advanced Life Support: X Basic Life Support: — Vehicle VIN Number: Make and Model: License Plate Number: Odometer: Year: Date of Expiration: _ Vehicle Number: Inspected by: Ambulance Representative; General Comments and/or suggestions: Date: Date: 1 Latimer County Department of Health & Environment Ambulance Inspection Checklist Certificate of Motor Vehicle Condition Dale of Cod Mention Unit Number TEMS Make CMG__ Model Suburban Color Scheme Black Colorado Slate License Number 104 UGR Year of Manufacture1992 VIN number IGKFICI6K5NJ72g454 Evaluation Check List Expiration Date _._5/31 /2013__ Item Acceptable Not Acceptable Conjoin Engine l Transmission Wheels & Tires Steering 7 Alignment Suspension Brakes / -- timid brake 7 Lights Electrical system Vehicle and patient compatIntent heater and cooling system / Glass 7 — Exhaust system / Fuel System / Body & sheet metal 7' Other comments The aodersigned, professing to be a motor vehicle inechute, has of Ibis date, evalunted the mechanical condition of the identified emergency response vehicle and determined that Ibis vehicle is in safe operating condition. Said evaluation does NOT wmrmte° future state of the emergency vehicle doe to coodiiirats beyond mechanic's control. Mechanic's SignNme fug `rittkr .r„rbV "I We grog s cnlie;jc' Company Name Address am• 112106 10 (AtI r� Date — - b1):37) Telephone 55) r.rl r j Zr_ Company Maine 11cv: 112006 Larlmer County Department of Health & Environment Ambulance Inspection Checklist Certificate of Motor Vehicle Condition Date of Certification Unit Number Med I Year orMani .tfacture 2003 Make Ford Model L-450 Wheeled Coach VIN nut ober IFDXE45F43HB28716 Color Schcnm_Wliite/Orange Colorado Slate License Number 091 IMF Espi:ation Date _5191/2013` Evaluation Check List Rent Amniotic Not Acceolable comments Engine 7 Transmission Wheels & Tires / Steering Alignment Suspension / Brakes Itnnd brake / Lights / Electrical system / Vehicle and patient compartment heater and cooling system 7 Glass Exhaust system Fuel System / Body @ sheet metal / Other comments re undersigned, professing to he a motor vehicle mechanic, has of this date, evaluated the mechanical condition of the identified emergency response vehicle and determined lint Ibis vehicle is in safe operating condition. Said evaluation does NOT warrantee Fiume state of the emergency vehicle due to conditions beyond mechanic's control. Mechanic's Signature Title /,YOri ' Loon J-; (,),J,i0, Lo Address hid (c)iti Date `L'16'- ;LO(y -YC3G' Telephone Latimer County Department of Health & Environment Ambulance Inspection Checklist Certificate of Motor Vehicle Condition Date of Certification Unit Number Med 2 Year ofMnnufhcture 2006 Make Ford Model Wheeled Coach Crusader VIN number IFDSS3Ap96IIB20607 Color Scheme_ White and Green Colorado Stale License Number 0871JGR Engine Item Evaluation Check List Acceptable Ng_tAgicutaIlc Expiration Date__5/7I /2017_ Comments Transmission Wheels Sc Tires Steering ,/ Alignment Suspension Brakes Hand brake Lights Electrical system Vehicle and patient cot apartment heater and cooling system Glass Exhaust system Fuel System Body & sheet metal Other comments The undersigned, professing to hen motor vehicle mechanic, has of this date, evaluated die mechanical condition of the identified emergency response vehicle and determined hat this vehicle is in safe operating condition. Said evaluation does NOT warrantee future state of the emergency vehicle due to conditions beyond mechanic's control. Mechanic's Signature (, az t3 Company Name Rev: 112006 `�eehtl: t, t,t bizI ) 12 — Title Dale r(rY09 5 iti/re. Fr (hit s 6u 'Pk 206 —YSl) s u Address Telephone Latimer County Department of Health & Environment Ambulance Inspection Checklist Certificate of Motor Vehicle Condition Date of Certification- Unit Number Med 4 Year of 1Mnnufachne 2003 Make Ford Model Wheeled Coach E-150 Antb V IN number I FDXE15FX31UTA31593 Color Scheme White/Orange Colorado State License Number 092 UGR Expirntion Date _5/31/2013__ Evaluation Check List km Acep111rle No! Acceptahie Comments Engine _ + Transmission Wheels agC Tires / Steering / Alignment Suspension Brakes Eland brake - / Lights /---- Electrical system / Vehicle and patient compel intent healer anti cooling system Glass 7 Exhaust system 7 Fuel System -- Body & sheet metal l Oilier comments The undersigned. professing to ho a motor vehicle mechanic has adds date. evahmted the mechanical cnndition (Ville identifier' mummy response vehicle and determined that this vehicle is in safe operating condition. Said evaluation does NOT wan'm(ee future state of the emergency vehicle duo to conditions beyond mechanic's control. Mechanic's Signature ,() 4 l l r.) Company Name Rev: 112006 fee Title i' ( ft (A L.- _IT Dat Address Telephone -1-(/4 is') Colorado State License Number 103 UGk Evaluation Check List Latimer County Department of Health & Environment Ambulance Inspection Checklist Certificate of Motor Vehicle Condition Date of Certification Unit Number bled6 Year ofbinnufnclure 2006__ Make Ford _ Model Wheeled Conch H-450 VIN number IFDXG45P26DA21099 Color Scheme. _White/Orange Expiration Date 5/31/2013 Irian Aceeabk NQLAcceplukk Comments Engine 7 - Transmission Wheels tgs Tires / Steering 7 Alignment / Suspension Brakes / !land brake / Lights Electrical system / Vehicle and patient compartment heater and cooling system / Glass Exhaust system /_ Fuel System / Body & sheet metal Other comments The undersigned, professing to he a motor vehicle mechanic, has of this date, evaluated the mechanical condition of the identi lied emergency Iespmtse vehicle and dctetntincd hat this vehicle is in safe operating condition. Said evaluation does NUT warrantee homy stale of the emergency vehicle due to conditions beyond mechanic's control. Mdehnnie's Signature Title yXvy 5 Catlr5c /ZI (to( l t 1�7/rt r J- -Fr cr(eliltI Ca Cowpony Name rev I r 2on6 A &dress ((T., ill Dale 2'/Z 2-Mi ,Y C37 Telephone Larimer County Department of Health & Environment Ambulance Inspection Checklist Certificate of Motor Vehicle Condition Dale ofCortificnlion Unit Number Med 9 Year of Manufacture 1999 Make Ford Model Wheeled Conch E-q5Q VIN number IFfl\Vl 30F5XHA26893 Color Scheme White/Orange Colorado State License Number 098 UGR Evaluation Cheek List Expiration Dole_ 5/31/2013___ Leal Acceptable Not cceptnble Comments Engine Transmission Wheels & Tires / Steering / - Alignment / Suspension / Brakes - Hand broke l ights Electrical system / Vehicle and patient compartment heater and cooling system / --- Glass 7 Exhaust system / Fuel System / Body & sheet metal / Other comments I'I ie um ers(gned, pi ofessmg to ho n motor• vehicle mechane, has of Ihts date, evaluated the mechanical condition of the identified emergency response vehicle and determined that Ihis vehicle is in safe operating condition. Said evaluation does NOT warrantee future stain of tha emergency. vehicle due to conditions beyond mechalPC's con inI. • `�ce1t\yl' c; c.i. Mechanic's Signature Title /) r Oci•i r) ;?arL 1-3,,/ Company Name acr. 112O6 Address 'ThV'r 5 6; icy? Fr Calbw Co U)ldd- 1 0 — Dote %121..1.6(, — ,Y-; 529 Telephone --'y,Act it) Company Name Larimer County Department of Health & Environment Ambulance Inspection Checklist Certificate of Motor Vehicle Condition Date of Certification Make Ford Color Scheme Colorado Slate License Nunibcr 090008 Unit Number Med Year of Manufacture 2005 Model Wheeled Coach E-450Amb VIN number _I PDXP45PR5HA15380_ White and Green Evaluation Check List Expiration Date -._5/31/2013 Item Acceptable Not Acceptable Comments Engine l Transmission Wheels & Tires / Steering / Alignment Suspension / Brakes / Hand brake / Lights / Electrical system 7 Vehicle and patient compliment healer and cooling system Gloss Exhaust system / Duel System / / Body & sheet metal Other comments 1 The undersigned, professing to be a motor vehicle mechanic has of Otis date, evaluated the mechnnicnl condition of the Identified emergency response vehicle and determined that this vehicle Is in safe operating condition. Said evaluation does NOT warrantee ft une state of the emergency vehicle due to conditions beyond mechnt'ic's contmi, Lott c„\ Meel ante's Signature Title Dale '-fir; 5 t-„ l i t, e Fr Grilifu Cu 9yG. - 266- $'n?' Address Telephone 1-6,6/1 Rev 112006 Latimer County Department of Health & Environment Ambulance Inspection Checklist Certificate of Motor Vehicle Condition Dale of Certification Unit Number Med 12 Year of Manufacture 2008_ _ Make Ford Model F-350 XLT Frazer type I VIN number I FD\VF36R34EB256 I? Color Scheme While and Green Colorado Stale License Number 099UGR Expiration Dale_ 5/31/2013 Evaluation Check List Engine Item Acceptable Not Acceptable Comments Tim l Sm lssien Wheels & Tires Steering Alignment / Suspension / Brakes Hand broke Lights Electrical system Vehicle and patient compnrlment healer and cooling system Glass Exhaust system Fuel System Body & sheet metal Other comments / The onderslgned, professing to ho n motor vehicle mechanic, has of this date, oval mted the mechanical condition of the identified emergency response vehicle and determined that this vehicle is in safe operating condition. Said evaluation does NOT wan on lee fu tare slate of the emergency vehicle due to conditions beyond mechanic's control. ec : (9 -7 1 I Mechanic's Signature Title Company Name Rev: 112006 Address Telephone Date 1felt% 5 Tel Ir5c. t'r Cell, P„ Co .`i2a 7-64 • ,5-41312_ Larimer County Department of Health & Environment Ambulance Inspection Checklist Certificate of Motor Vehicle Condition Date of Cerlifiention Unit NumberMed I Year of Manufacture 2008 Make_ Ford_._ Model F-350 X LT Frazer Type I VlNnunrber�IFDWF36R5SEB256IS Color Scheme While and Green Colorado Slate License Number I 0DUGR Expiration Date -5/31/2011 Evaluation Check Lisl Item i ci it alte Not Acceptable Comments Engine 7 Transmission re Wheels & Tires / Steering 7 Alignment Suspension Brakes Hand brake Lights / / Electrical system Vehicle and patient comportment heater and cooling system 7 Glass Exhaust system Fuel System / Body & sheet metal / Other comments The undersigned, professing to be a motor vehicle mechanic, has of ibis date, evaluated the mechanical con( ti of Ilse id eat' lc< emergency response vehicle and determined hat this vehicle is in safe operating condition. Said evaluation does NOT warrantee Inmate state ol'the emergency vehicle due to conditions beyond mechanic's control. t��11tr0trt- Mechanic's Signature 'Ville VA nice IP /17/L2 -- Dane Company Name Address Telephone REP' 112006 Larimer County Department of Health & Environment Ambulance Inspection Checklist Certificate of Motor Vehicle Condition Date of Certification Unit Number Med I S Year of Manufacture 2008 _ tvinke_Fordl Model F-350 XLT Frazer Type I YEN number _I FDWF36R7SEB2S619 Color Scheme While and Green Colorado Slate License Number-_ 101 UOR Evaluation Check List Expitnlion Date 5/3112013 Item Acceptable Not Acce h — ----_. Continents --- -� - Engine • transmission / Wheels & 'rites Steering Alignment / % -- Suspension Brakes / Hand brake Lights Electrical system / Vehicle and paticnt compartment heater and cooling system Glass / Exhaust system 7 — - Fuel System Body & sheet metal ' Other comments le un enstgned, pIofessmg In ba n n10(01 VClnlelo mechmne, his of 1111$ date, ovatemite( le nicehmdcal condition of the identified emergency response vehicle nod determined that this vehicle is in safe operating condition. Said evnluotion does NOT warrantee future state of the emergency vehicle due to conditions beyond mechanic's control. Mechanic's Signature l'?„/_ lY )3a r ,, )70 „I: Gcl\I1' C G r' Title tiro c, (Ut kyC FT (01)i to lr. —1141 (Pfrk Dale `>'t 26te • K d Company Name Address Telephone Rev, 1O006 J I1 ,•(al Y�7�.•vr Company Nine Rev: 112006 Larimer County Department of Health & Environment Ambulance Inspection Checklist Certificate of Motor Vehicle Condition Date of Cerlilicnlion Unit Number Med 16 Yenr of Manufacture 2008 Make Ford_ Model F•350 Xl.T Frazer Type 1 VIN number ^I FDWF36R6SED13130 Color Scheme Colorado State License Number___-_093UGR While 011(1 Green Evaluation Check List Expiration Date 5/31/2013 11cm Acceptable Not Acceptable CW11IFcnis Engine Transmission isr Wheels & fires / Steering Alignment / Suspension / Brakes Hand brake / Lights 7 Electrical system Vehicle and patient compartment lender and cooling system l Glass / Exhaust system Fuel System j Body & sheet metal Other comments The undersigned, professing to he a motor vehicle nmechnnie hos of this date, evaluated the inecIan tenl con( ion of the Edenhftet emergency response vehicle and determined that This vehicle is in sole operating condition. Said evaluation does NOT warrantee flume state of the emergency vehicle due to conditions beyond mechanic's control. Mechanic's Signature lithe IOf/ `' Coll ;je (oiliIli (it__ Address Telephone Latimer County Department of Health & Environment Ambulance Inspection Checklist Certificate of Motor Vehicle Condition Dale of Certification Unit Number Ivied 17 Year of Manufaclurc 2008 Make Ford_ Model __ F-350XLTrainier Type I___VIN number_ IPDWF36RX8ED13129 Color Scheme White and (;teen Colorado Slate License Number_ 094UUR Expiralion Date 5/3 I/2013 Evaluation Check List item Acceptable Not Acceptable Comments Engine "Transmission 7 - Wheels &'fires Steering Alignment Suspension Brakes Band brake Lights i Electrical system Vehicle and patient compartment heater and cooling system Glass Exhaust system Fuel System Body & sheet metal Other comments I'he undersigned, professing to be a inn ow vehicle mechanic, has ofIIns date, evaluated the mechanical condition of the Identified emergency response vehicle and determined that Ibis vehicle Is in safe operating condition. Said evaluation does NOT wanantce film re shoo of the emergency vehicle due to conditions beyond nnechouic's control. Mechanic's Signature Title Wog j Lv/lr5e Lim Co Company Name Address Rc¢ !1200(, E7� 2t'f 1 9— Dat "Telephone Lerliner County Department of Health & Environment Ambulance Inspection Checklist Certificate of Motor Vehicle Condition Date of Certification Unit Number Med IX Year of Manufacture 2008. Make Ford Model F-350XLT,IXdlErnzcrType 1 VIN number__ IFDWX37R38ED13131 Color Scheme White and Green MOM ion Dale 5/31/2013 Colorado Slate License Number 095UOR Rvnluntion Check List Item Moot N.roplable Comments Engine 7 Transmission Wheels & Tires / Steering Alignment Suspension / Brakes / Hand brake Lights f Electrical system / Vehicle and patient congmdment healer mid cooling system / Glass Exhaust system 7' Fuel System .� Body & sheet metal Other comments The nndeisigned, professing to he a motor vehicle mtchnnic, has of this date, evnhmted the mechanical condition ortlie tdean lac emergency response vehicle and determined hal this vehicle is in sale operating condition. Said evaluation does NOT warrantee future state of the emergency vehicle due to conditions beyond mechanic's control. Mechanic's Signature ftry )3r,r, Foe d Company Name CI -t°. V (i1. G 49 — Title Date Heyvi/ S Lott PT (Oh n $ (rr `%7G pia 1 sV Address Telephone Hvv. I [2006 Larimer County Department of Health & Environment Ambulance Inspection Checklist Certificate of Motor Vehicle Condition Date of Certification Unit Number Ivied 19 Year of Manufacture 2009 _ Make_ Ford Model _ _F-950 XLT Frazer Typo I VIN number IFDWF36Rd9EA60327 Color Scheme While and Green Colorado Slate License Number _I02UGR Expiration Dale 5/91/2013 Evaluation Check t.ist item Acceptable Not Acceptable Continents Engine Transmission Wheels & 'fires Steering Alignment Suspension Blokes Hand brake Lights Electrical system Vehicle and patient compartment heater and cooling system Glass Exhaust system Fuel System Body & sheet metal Other comments The undersigned, professing to be n motor vehicle met beide, has of this dale, evntunled the mechanical condition oflhe identified emergency response vehicle and determined that this vehicle Is in safe operating condition. Said evaluation does NOT rvmranlce fimne stale of the emergency vehicle duo to conditions beyond mechanic's control. hdechanie's Signature Title :7patilt) l�Xrr, Company Name Rev: I 12C06 )zva Li (Ire 11 /&/hart 1a L Dale Address Telephone 1 Larimer County Department of Health & Environment Ambulance Inspection Checklist Certificate of Motor Vehicle Condition Date of CerliNation Unit Number Mcd 20 Year of Manufacture 2010 Make_Ford_ Model F-450 XI ,T 4X4 Frazer Type I VIN number I FDAF'HR7AfiA90177 Color Scheme While and Green Colorado Stale License Number — 089 UO R_ Evaluation Check Lisl Iixpira I ion Dale 5/3 I/20 I 3 Item Mgcptablo N Not Acceptable Comings Engine Transmission / Wheels tge Tires / Steering ----- Alignment / Suspension / Brakes / Hand brake / Lights / Electrical system / Vehicle and patient compartment heater and cooling system Class / Exhaust system Fuel System 7 Body & sheet metal / Other comments The undersigned, professing to be a motor vehicte ineelinnic, has of this date, evaluated the mechanical condition of the tdenItIio emergency response vehicle and determined lint this vehicle is in safe operating condition. Said evaluation does NOT warrantee figure state of the emergency vehicle due In Lnuditions beyond mechanic's cmnrnt. vlechnnit's Signature Title Ines .5 i.oklrL f it rv, Fr 4/4 1104 ca p /(of • Company Name Rev. 112006 h� �d ¶ cjAr to 9111) -- Date Address Telephone Larimer County Department of Health & Environment Ambulance Inspection Checklist Certificate of Motor Vehicle Condition Dale of Certification Unit Number_ Ivied 21 Year of Manufacture 2010 Make_Forcl Model F-,IS0XLT4X4 Frazer Type l_. VIN number IFDWF3GR3AED3Sllit Color Scheme While and Green Colorado Stale License Number 096 UGH_ Expiration Date S/31/2013 Evaluation Check List Item Engine _ Trnnsmission Wheels & Tires Acceptable Not Acecute hie Comments Steering Alignment Suspension Drakes Hand brake Lights 2 Electrical system Vehicle nod patient compartment heater and cooling system Glass Exhnusl system I / Fuel System flody & sheet metal Other comments The undersigned, professing to be a motor vehicle mechanic, has of this date, evaluated the mechanical condition of the identified emergency response vehicle and determined that ibis vehicle Is in safe operating condition. Said evaluation does NOT warrantee future state of the emergency vehicle due to conditions beyond mechanic's control. Mcchnuic's Signalme -Ia). uol� t) Compnnv Nane Rev: 112006 l-eekylte;er IoIIo (0— Tille Dale sort 'I folfoe L ) ;665-(> Address Telephone Larhner County Department of Health & Environment Ambulance Inspection Checklist Cernlleate of Motor Vehicle Condition Date of eerlificalion Unit Number Med 22 Year of Manufacture _201 I lvlake_Dodge__ Model Dodge Rain 350 Type I VIN number_ 3D6WF4ELXUG574309____ Color Scheme While and Green ColorndoStole License Number 088UGR ilxpiraliouDale 5/31/2013 Evaluation Check List flea A&ce0laltL Engine Transmission Wheels & Tires l Not Acceptable Comments Steering Alignment Suspension Brakes Hand broke Lights Electrical system Vehicle and pallent comportment healer and cooling system Glass Exhaust system K Fuel System Body & sheet metal Oilier comments The undersigned, professing to be a color vehicle meclinnic, has of this date, evaluated the mechanical condition of the identified emergency response vehicle and determined hat lids vehicle is in sale opouttog condition. Said evaluation does NOT warrantee future state of the emergency vehicle duo to conditions beyond mechanic's control. Mechanic's Signature Title km( 5 Cclf=fie :'/�tacii[) ;127ArV J`Urof Fr'vIj tin 70 Company Name Address `'W XSTSt Telephone Rev: 112005 Larimer County Department of Health & Environment Ambulance Inspection Checklist Certificate of Motor Vehicle Condition Date of Certification/0-/0.12. Unit Number Med23 Year ofManufacture 2012 Make Mercedes_ Model Mercedes Type 111 Amb_ _ VfN number WDAPF3CC9C9504702 Colo• Scheme White mid Green — Colorado Stale License Number 116 UGR Expiration Date 5/31/2013 Evaluation Check List Item Engine Transmission Wheels & Tires Steering Alignment Suspension Brakes Hand brake Lights Electrical system Vehicle and patient compartment heater and cooling system Glass Exhaust system Fuel System Body & sheet metal Other comments Acceptable Not Acceptable Comments 9,-r • 'Irani - The undersigned, professing to ben motor vehicle mechanic, has of this date, evaluated the mechanical condition of of th�S emergency response vehicle mind determined that this vehicle is in safe operating condition. Said evaluation does NOT warrantee future state of the mergency vehicle due to conditions beyond mechanic's control, •"/ _(26441e r lietChanic's Signa� Title .S?eciyi /16/or Coy; Company Name Rev:111006 ?o- Io - 12. Date Address Telephone EXHIBIT B Poudre Valley Hospital EMS Ambulance Service License Application Denial (December 21, 2012) DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT 1555 North 17th Avenue Greeley, CO 80631 Weo: www.weldhealth.orq rubu cxcn Health AdmInl.Vtllon Publlo Hein I Clinical Enwlanmenlel Health 40mnWnlalbe, Emerpeocy Pmperyb,ses VIIaI Records SSMces Sonless Eeucsllan S Planning I Response TW 010,304.6410 Tele. 970.304,0420 Tare: 920,309.6415 T•e, 970,304,0470 IS,: 970.354.6420 Fec. 970,300,0412 For 010.3048410 Few: 970.304.6411 For. 970.304&52 Par, 970.309,5409 de vlslan: Tecate/ eel the communities we sew, we we *ethnic lo mike Weld County The needled pone m eve, ,pow, work did pay, December 21, 2012 Steve Main (via email at scm@pvhs.org) Poudre Valley Hospital Emergency Medical Service 2315 East Harmony Road, Suite 200 Fort Collins, Colorado 80528 Subject: Ambulance Service License Application — Poudre Valley Hospital EMS Dear Mr. Main: The Weld County Department of Public Health and Environment has reviewed your application, submitted on November 8, 2012, for an Ambulance Service License. I am hereby denying the application. The application is being denied for the following reasons: • Poudre Valley Hospital EMS (PVH EMS) does not have its primary base of operation located in Weld County, as required by the definition of "ambulance service license," found in Section 7-1-30 of the Weld County Code, and, • PVH EMS is not providing "primary care" in Weld County, as defined in said Section 7-1-30, because it does not have an agreement or contract with Weld County to do so. If PVH EMS wishes to appeal this decision to the Board of County Commissioners, it may do so by availing itself of the procedures found at Section 2-4-10 of the Code, a copy of which is enclosed herein. If you have any questions, please contact Trevor Jiricek of my staff at 970-304-6415, X2214. Sincerely, Mark E. Wallace, MD, MPH Executive Director and Ilealth Officer Ec: Bruce Barker, Weld County Attorney WELD COUNTY CODE (available on-line at www.co.weld.co.us) Sec. 2.4-10. Appeals process. The Board of County Commissioners shall act as a board of appeals to hear complaints on actions taken by County boards, commissions and departments. Except for decisions made by the Board of Adjustment and Uniform Building Code Board of Appeals, procedure for appeals shall be as set forth In this Chapter, by resolution of the Board, or as otherwise provided by law. A. Any person appealing an action by a County board, commission or department to the Board of County Commissioners shall file such a complaint, in writing, with the Clerk to the Board within sixty (50) days of the incident in question. B. Such complaint shall Include: 1. The name of the employee, board, commission or department against which the complaint Is made. 2. A description of the basic facts involved in the complaint. C. The Clerk to the Board shall schedule a hearing with the Board of County Commissioners, to be held within fifteen (15) days of the filing of the complaint, and shall notify all parties involved in the incident. D. The Board of County Commissioners shall hear all the available facts pertinent to the incident, may schedule a second hearing within thirty (30) days following the initial hearing if the Board determines such a need, and shall render a determination within thirty (30) days of the final hearing. E. No person shall be denied the right to appeal, provided that he or she complies with the administrative procedures established by the Board. (Weld County Codification Ordinance 2000-1) EXHIBIT C Poudre Valley Hospital EMS — Weld County Mutual Aid Agreement (May 30, 1990) RESOLUTION RE: APPROVE MUTUAL AID AGREEMENT WITH POUDRE VALLEY HOSPITAL PARAMEDIC SERVICES AND AUTHORIZE CHAIRMAN TO SIGN WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to Colorado statute and the Weld County Home Rule Charter, is vested with the authority of administering the affairs of Weld County, Colorado, and WHEREAS, the Board has been presented with a Mutual Aid Agreement between the Weld County Ambulance Service and the Poudre Valley Hospital Paramedic Services, and WHEREAS, the terms and conditions are as stated in the Agreement, a copy of which is attached hereto and incorporated herein by reference, and WHEREAS, after study and review, the Board deems it advisable to approve said Agreement. NOW, THEREFORE, EE IT RESOLVED by the Board of County Commissioners of Weld County, Colorado, that the Mutual Aid Agreement between the Weld County Ambulance Service and the Poudre Valley Hospital Paramedic Services be, and hereby is, approved. RE IT FURTHER RESOLVED by the Board that the Chairman he, and hereby is, authorized to sign said Agreement. The above and foregoing Resolution was, on motion duly made and seconded, adopted by the following vote on the 10th day of October, A.D., 1990. A ((( II !� I BOARD OF COUNTY COMMISSIONERS ATTEST: f J ,�,��Vµ ✓;..`;'... NELUNTY, COLORADO Weld County n fi{ nty Clerk to the Board �� ppty ler to`the Boa APPROVED AS TO FORM: County Atfasel torney C.ene R. Brantnec, Chairman eorge E nedy, ro-1014, EXCUSED DATE OF SIGNING - AYE Constance L. Harbert 900926 MUTUAL AID AGREEMENT Date of this Agreement: MAY 30 , 19 90 Agencies to this Agreement: WELD COUNTY AMBULANCE SERVICE by and through the Board of County Commissioners of Weld County, Colorado, and POODRE VALLEY HOSPITAL, PARAMEDIC SERVICES FORT COLLINS, COLORADO These agencies maintain paid and/or volunteer emergency service personnel and equipment. It is to the mutual benefit of each agency to assist the other. As a result, both agencies agree as follows: 1. To respond to requests for assistance from the other agency whenever possible. However, it shall be entirely within the discretion of the management a£ the requested agency as to whether and/or what personnel and equipment will respond to the request. 2. This Agreement does not create an employment relationship between the agencies. Each agency agrees that its personnel do not become employees of the other agency as a result of this agreement. Each agency's equipment and personnel shall remain the responsibility of that agency even when responding to a request under this Agreement. Each agency's personnel do not become entitled to any employees' benefits provided by the other agency as a result of this Agreement. Each agency shall provide necessary Worker's Compensation Insurance for its own personnel at its own coat and expense. 3. Each agency waives all claims against the other agency for compensation for any loss of or damage to equipment and for any loss, damage, personal injury or death sustained by its personnel, which occurs as a result of the performance of this Agreement. 4. Each agency agrees that the equipment, actions, methods and practices of its personnel shall conform to the applicable requirements of Colorado law and to acceptable methods and practices of emergency response services. 5. This Agreement may be supplemented with various exhibits setting forth apecifio areas of response, protocol, communications, and other procedural matters. These 9C002o supplements must he adopted, signed, and dated by both agencies. 6. This Agreement shall supersede and replace any and all agreements, contracts, and written and/cr oral understandings in existence prior to the execution of this Agreement. 7. No alteration of the terms of this Agreement shall be valid unless made in writing and signed by the authorized representatives of the parties to this Agreement. 6. Nothing in this Agreement shall be construed to create a cause of action and/or civil liability remedy in any person not a party to this Agreement. This Agreement exists for the sole benefit of the parties to the Agreement. The Agreement shall not be construed to create a duty by either party to any third party where no such duty otherwise existed. 9. This Agreement shall take effect upon execution by authorized representatives to each party. This Agreement shall remain in effect until such time as either agency gives sixty (60) days advanced written notice to the other agency of its intention to terminate or amend. IN WITNESS WHEREOF, the parties above named have executed this Agreement on the 9n day of HAY , A.D., 19 90 AWES A / ,; / /9414-9€6; 9 �i Clerk 'to. the Rc. .51 uty clerk td O)1f -.Hw•./ oar Bohai' OF COUNTY COMMISSIONERS WELD COUNTY, COLORADO Poudra Valley Hospital P it c.e„f.a. DCG92S airman EXHIBIT D Affidavit of Steven C. Main Before the Weld County, Colorado Board of County Commissioners 1 150 O Street, P.O. Box 758, Greeley, CO 80632 In the Matter of the Appeal of the I)enIal of the Application for an Ambulance Service I.icense of POUDRE VALLEY HOSPITAI, EMS AFFIDAVIT OF STEVEN C. MAIN 1, Steven C. Main. being first duly swum, depose and state: My full name is Steven C. Main and I reside in Foil Collins, Colorado. 2. I am over the age of 18 years and am of sound mind. I am fully competent to testify to all matters set forth in this Affidavit based upon my own personal knowledge. 3. I am presently employed by Poudre Valley I lealtheare, Inc., which owns and operates Poudre Valley IIospital EMS, previously known as Poudre Valley Ilospital Paramedic Services (" I'V Ii")_ I hold the position of EMS Manager and, in that capacity, oversee emergency medical services and ambulance services for PVII. 4. I participated in the completion of PV11's Ambulance Service License Application (the "Application'), which was submitted to the Weld County Department of Public I lcalth and Environment on November 8, 2012. I believe that PVI I's Application provided all of the information requested in the accompanying instructions. �. 1 have reviewed and am familiar with Chapter Seven of the Weld County Code (the "Code''), which addresses the permitting of ambulances and the licensing of ambulance services. As a consequence, 1 am aware of the definition of "primary care" set forth in Section 7- 1-30 of the Code. 6. I have personal knowledge of a Mutual Aid Agreement between PVII and Weld County Ambulance Service, dated May 30, 1990. On January I, 2013, I confirmed that this Agreement remains in effect via e-mail with Assistant Weld County Attorney Bob Choate. Nly e-mail correspondence with Mr. Choate is attached to this Aiidarit. 7. In accordance with the Mutual Aid Agreement, PVH has provided primary care in Weld County. 8. I have reviewed and am litmiliar with the Rules Pertaining to I.iccnsure of Ground Ambulance Services promulgated by the Colorado State Board of Health, including the definition of the term "based'' included in Rule 2.1. 9. To my personal kowledge, PVH maintains the primary base of operation liar its Weld County ambulance service at 6906 'tenth Street, Greeley Colorado 80634. 10. I am aware that ambulance service providers that do not maintain primary bases of operation in Weld County recently applied for, and were granted, Weld County ambulance service licenses. As the attached e-mail correspondence indicates, I was advised by Assistant County Attorney Choate that these providers did not have contracts or agreements with Weld County other than Mutual Aid Agreements similar to that entered into by PVII. Mr. Choate provided me this information in response to my request for documents made in accordance with the Colorado Open Records Act. 11. I have participated in negotiations between PVH and the Windsor -Severance. Johnstown, and Milliken Fire Protection Districts regarding proposed ambulance and emergency medical services agreements. To my personal knowledge, each of these three tire protection districts intends to enter into such contracts with PVH. This concludes my Affidavit. Steven C. Main STATE OF COLORADO SS. COUNTY OF LA RIMER The foregoing Affidavit was subscribed and sworn to before me by STEVEN C. MAIN in the County of Larimer, State of Colorado, this 21st day of January 2013. Witness my hand and official seal. My commission expires: (SEAL) IL I _ C (5Oi ,)C <-\ Notary Public 3 ,co'CMf., ;; >>> Bob Choate <bchoatecisco.weld.co.us> 0103/13 8:39 AM >>> Mr. Main, Dr. Wallace forwarded your open records request to me to make sure we're providing you with what you're requesting. My understanding is that you have received the dispatch agreement between Banner and Weld County, as well as a list of those entities who are licensed to conduct ambulance services in Weld County. Other than the mutual aid agreements with various entities (Including PVH), there are no other agreements with any other licensed ambulance service providers. We can provide the mutual aid agreements to you if you like. We'd like to be responsive to your request. If you think there's something here that you do not already have, feel free to contact me directly and I'll do what I can to help you out. Thanks much, Bob Choate Assistant Weld County Attorney From: Steve Main [scm@pvhs.org] Sent: Friday, December 28, 2012 3:28 PM To: Mark Wallace Cc: Bob Choate; Taiya DeAngelis; Trevor Jlrlcek Subject: Re: Follow-up with documents referenced in "Response to your requestfor documents" Thanks, they came through that time. The contracts I was looking for were not for dispatch though. I was looking for the contract or agreement between , Weld County and each agency licensed to provide a transport ambulance service in the county. If those could be provided it would be much appreciated. Thanks, Steve Steve Main, EMS Manager Hello