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Home My WebLink About20153890.tiff RESOLUTION RE: APPROVE APPLICATION FOR TIER I EMERGENCY MEDICAL SERVICES LICENSE AND AUTHORIZE CHAIR TO SIGN - PLATTE VALLEY AMBULANCE SERVICE 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, pursuant to Section 7-2-100 of the Weld County Code, the Weld County Department of Public Health and Environment and the Weld County Emergency Medical/Trauma Service Council have reviewed the application of the Platte Valley Ambulance Service for a Tier I Emergency Medical Services License and recommend approval, and WHEREAS, after review, the Board deems it advisable to approve said Application for a Tier I Emergency Medical Services License, a copy of which is attached hereto and incorporated herein by reference. NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld County, Colorado, that the application of the Platte Valley Ambulance Service for a Tier I Emergency Medical Services License be, and hereby is, approved. BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to sign said license. The above and foregoing Resolution was, on motion duly made and seconded, adopted by the following vote on the 14th day of December, A.D., 2015. BOARD OF COUNTY COMMISSIONERS W D COUNTY, CO ORADO ATTEST: Jidda AA_ Wti did& ' Barbara Kirkmeye , Chaim Weld Co ty Clerk to the Board EXCUSED /4i Mike Freeman Pro-Tern BY: �. k$ ',i�%i •i, Deputy Clet<to t e eZ are/�F'�•"` , / \ 1161 t ;� Sean P. Conway AP ED O FOR 1 �� LCL�� c6(7_," �►' �r� Julie A. Cozad County Attorney EXCUSED Steve Moreno ///4//1-( Date of signature: kh—) T� 2015-3890 / HL0047 1861 Memorandum IX1 TO: Barbara Kirkmeyer, Chair 1/3t N T Y ,-- Board of County Commissioners FROM: Mark E. Wallace, MD, MPH, Executive Director Department of Public Health & Environment DATE: November 23, 2015 SUBJECT: 2016 Applications for Ambulance Service License Enclosed for the Board's review are eleven applications for ambulance service licenses pursuant to Chapter 7 of the Weld County Code (WCC) from the ambulance service providers listed below. Chapter 7 pertains to Emergency Medical Services. The Weld County Emergency Medical/Trauma Service (EM/TS) Council reviewed the application for each ambulance service on November 18, 2015. The Council recommended that each service receive a license based on their tier level. The Department has reviewed the applications and has deemed all ambulance services listed below to have met all applicable licensure application requirements found in Chapter 7. As such, I am recommending licensure for the following ambulance service providers. Tier I Tier I continued Tier I continued Frederick— Firestone Fire Poudre Valley EMS Platte Valley Ambulance Protection District 3509 South Mason Service EMS 8426 Kosmerl Place Fort Collins, Colorado 1600 Prairie Center Parkway Frederick, Colorado Brighton, Colorado Front Range Fire Rescue Southeast Weld Fire 101 South Irene Avenue Protection District Milliken, Colorado 65 East Gandy Avenue Keenesburg, Colorado Tier III Mountain View Fire Thompson Valley EMS Colorado Motocross Medics Protection District 4480 Clydesdale Parkway 729 Remington Street 3561 Stagecoach Road, Unit 200 Loveland, Colorado Fort Collins, Colorado Longmont, Colorado Banner Health/Northern Windsor Severance Fire Stadium Medical Colorado Medical Center Protection District 695 Canosa Court Paramedic Service 100 North 7th Street Denver, Colorado 1801 16th Street Windsor, Colorado Greeley, Colorado O E11E11E1lEIMHMIEMLEIMEMMIH1MIE11E1Mnlln O. il W ► ` ZT:. 1.16 .2 Q CC Irr 0 3 U IN_ z _ M O. ,.. z (U Eto =O 4:3 3- E Um I CO w vi IC r, a M O Z W c Z w CI IJJ U < Z — B 1-- ZIne Z 5 re O � � 3._ me 2 0 k> la o i- J W > C7 vJ 0Z N O y a W Z U z E. 83._ "g ix 5 `' V O J z Q z Da_ "c:Lt Z 1 ii•-i 3 1— '� W E O 3- D a 0 03 <u m' g m " W3 Q ' 3_ v +r o1—, ,U, 6 0 c Ig. ag i � ..� � z z o. ,� 1..2 Z •mg 'Q o W H d h Ca .7I' .§. N U _ W � Z o 3 .2 W a1 N CD J W a Z x o 00 C "S. W N W U Z rro SI M � 1 g_ 0. W m � (...(Ti 3,- 0 In g ^nom',' E. I W p a E. lE. ,,. U @ o OD Ime J WI 13. l= Z U ,, E. E. D CI L 1.0- W e vii .— W = .g. o mg, U * _.. cu "a6.41612.6.0*.0" DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT (+1. 1555 N. 17th Avenue pi . 3 t Greeley, CO 80631 Pub*Health Web h!tp iiv.ww.comeld.co.usiDepartments/HealthEnvirontrienthridex Ma)!r Health Administration Public Health S Clinical Environmental Health Communication, Emergency Preparedness Vital Records Services Services Education L Planting &Response N T T ire 9 6 3}t 64 t 2 Te!e 970 304.6420 Tele 5'0 304 6445 Tele 970 304 6470 Tele:970 304 6420 Cj 0 V_ Fa. 470 377 541 Fax 970 304 6416 F04 570 3)4 6411 Fax 970?04 6452 Fax 970 304 6469 2. 0. . c. Togeh.e,aaM the communities we serve,we are wtrkrng fo make Weld County the hea!rh,est place to tote warn,work and pray November 4. 2015 David Bressler Chair Weld County Emergency Medical/Trauma Service Council Via email: Dave.Bressler(c!hannerhealth.com SUBJECT: 2016 Platte Valley Ambulance Service EMS Application NOTICE OF EMERGENCY MEDICAL SERVICES LICENSE APPLICATION TO THE WELD COUNTY EMERGENCY MEDICAL/TRAUMA SERVICE COUNCIL The Weld County Department of Public Health and Environment has received and is in process of reviewing an Emergency Medical Service License Application from Platte Valley Ambulance Service. Attached to this document are the Ambulance Service License Application. and Maps of its proposed Service Area. On behalf of the Board of County Commissioners, the Department is requesting the Emergency Medical/Trauma Service Council review the attached documents in accordance with Section 7-2-100.B.5. of the Weld County Code (enumerated below). The Department will forward your recommendation to the Commissioners. Below are the most applicable portions of the code: Weld County Code,7-2-100.B.5 The recommendation of the Weld County Emergency Medical/Trauma Service (EM/TS) Council as to whether or not the issuance of the license will contribute to an efficient. effective, and coordinated emergency medical response to residents of the County. The EM/TS Council shall also provide: a. Recommended Service Area. h. Recommended Pier of License. Weld County Code,7-2-10. No person shall provide or operate an ambulance service publicly or privately in the County unless that person holds a valid license to do so issued by the Board of County Commissioners, except as provided in Section 7-2-80 below. The fee for said license shall be set by separate ordinance. The license shall issue only in the following tiers of service: tier I: Licensure authorizing for Primary Care.as defined in Section 7-1-30 of this Chapter. Tier II: Licensure authorizing for transports of patient(s)to and from licensed medical facilities. This licensure does not provide for Primary Care,as defined in Section 7-1-30 of this Chapter Fier III: Licensure authorizing for Standby Service, as defined in Section 7-1-30 of this Chapter. it A. The Board of Counts Commissioners reserves the right to amend these rules and regulations and any other individual conditions of licensing as applied to any particular license, as needed in keeping with its legislative function and in order to implement the policy of the State of Colorado that the regulation and control of ambulance licenses is in the exclusive purview of the boards of county commissioners. Persons or firms seeking application and approval of any ambulance license under this Chapter acknowledge that Weld County may contract with specific ambulance service provider(s) which w ill serve the emergency ambulance need of Weld County and participating municipalities. Please forward the Councils recommendation to the Department including minutes of the EMS Council meeting pertaining to this application. Please do not hesitate to call me should you have any questions. Sincerely, • Kevin Antuna Environmental Health Specialist Environmental Health Services Recommendation of the Weld County Emergency Medical/Trauma Service Council for: Platte Valley Ambulance Service As required in Section 7-2-100.13.5.. the F:MTS Council should review the application to assess as to whether the ambulance service ++ill contribute to an efficient,effective, and coordinated emergency medical response to residents of the Count)? Please include any findings related to response time, coordination with other ambulance services, location. service area.etc. that is the basis for the Council's recommendation: FINDING #1: No findings were presented or received at_the time of the review. There was no one in attendance at the meeting. FINDING #2: There have been no issues reported to the LMTS Council concerning the service provided to the citizens and visitors to the Weld County Service area. FINDING #3: FINDING #4: Recommended Level of Service: Tier 1 Tier 2 Tier 3 Recommended Service Area: As listed on the application. Other EMTS Council recommendations or comments: Recommend approval of a Tier 1 License_as requested lior the service area listed on application. Recommendation By: '-i Date: 1I-18-2015 DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT qv 1555 North 17th Avenue Greeley, CC) 80631 t Public Health www.weldhealth.org Health Administration Public Health L Environmental Communication, Emergency Preparedness Vital Records Clinical Services Health Services Education&Planning 1 Response Tele:970-304-6410 Tele:970.304-6420 Tele:970-304-6415 Tele:970-304-6470 Tee:970-304-64`0 Fax: 970-304-641 2 Fox: 970-304-6416 Fax: 970-304-6411 Fox: 970-304-6452 Fax: 970304.6469 Ott vision:Together with the communities we serve,we are working to make Weld County the healthiest place to Ilve,learn,work,and play AMBULANCE SERVICE LICENSE APPLICATION Date ofApplication: Friday, October 23, 2015 Name of Ambulance Service: Platte Valley Ambulance Service Owner: Name: Platte Valley Medical Center Address: 1600 Prairie Center Parkway, Brighton, CO 80601 Phone Number: (303) 498-1600 Operations Manager: Name: Carl A. Craigle, Jr. NR-Paramedic (Chief Paramedic) Address: 1750 E. Egbert Street, Brighton, CO 80601 Phone Number: (720) 685-8439 Email: ccraigle@pvmc.org Medical Director: Name: Candace Harrod, MD Address: 1600 Prairie Center Parkway, Brighton, CO 80601 Phone Number: (303) 498-J.600 Name and address of each stockholder of partner owning 10%or more of the outstanding stock of the company of having more than a 10%ownership interest(if applicable): Platte Valley Ambulance Service is a department of Platte Valley Medical renter, community-owned, non-profit hospital _ As such we ve no O olders Attached is a current list of the, bgard of directors What area otsWeld County will be served by this company? Please attach a map indicating the service area. Towns of Lochbuie and Wattenburg. We also provide mutual-aid coverage for the communities of Ft . Lupton, Keensburg, Prospect Valley and Roggen. Occasionally asked to provide coverage for the town of Platteville. How many ambulances do you operate? Six, three of which are normally on duty and three in reserve. Page 2 Location and description of the place(s)from which this ambulance service will operate. If there are more than two locations, attach a separate sheet with the above information. Location#1: Street Number: 1750 E. Egbert Street City: Brighton State: CO Phone: (303) 981-8740 Location#2: Street Number: PVAS Station #2, on Platte Valley Medical Center Campus City: Brighton State: CO _ Phone: (303) 498-1820 As required in Section 7-3-30 of the Weld County Code Ordinance and Chapter 4 Section 6 of the CDPHE Emergency Medical and Trauma Care System regulations, as of the date of the application,are you in compliance with the minimum data collection and reporting of transportation and/or treatment of patients: ®Yes ❑No As required in Section 7-3-40 of the Weld County Code and Chapter 3 Section 3 of the CDPHE Emergency Medical Services regulations, as of the date of the application, are you in compliance with the reporting requirements of the agency profile: ®Yes ❑No Please read carefully: Sec. 7-2-10 License for Ambulance Service.No person shall provide or operate an ambulance service publicly or privately in the County unless that person holds a valid license to do so issued by the Board of County Commissioners, except as provided in Section 7-2-80 below. The fee for said license shall be set by separate ordinance. The license shall issue only in the following tiers of service: Tier I: Licensure authorizing for Primary Care, as defined in Section 7-1-30 of this Chapter. Tier II: Licensure authorizing for transports of patients that originate in Weld County from licensed medical facilities. This licensure does not provide for primary care, as defined in Section 7-1-30 of this Chapter. Tier III: Licensure authorizing for Standby Service,as defined in Section 7-1-30 of this Chapter. Level of Service Requested: El Tier I O Tier II O Tier III Page 3 Page 5 Location and description of the place(s)from which this ambulance service will operate. (continued) Location#3:(Greater Brighton Fire Protection District Station 51) Street Number:425 South Main Street City:Bri hto State: CO Phone: 303-659-0123 Location#4:(Greater Brighton Fire Protection District Station 51) • Street Number:5 Firehouse Road City: Brighton State: CO Phone: 303-659-1035 • 1 Oki 1 CO twit . WI CV t . ...•.. z• r I CO 0 Z 0 .N cc - a _al __-----4 a .0_6 , ILIIIII ILIU lab tr) WM am WO 111 .r , , 1 I • } N r «•rww • I i a Zc co) -P + mar i 5 a1,IC E 0 I i a 2. i _0) ai.0,...,„„ 1 iiii„, 1 1 M ,i„ Im 1,... qi.) , , . , ` „, ama Lull massira 0 mit Ilk (le w^.x " t , ,. .. irpo;.,, irallill .1r \ 4 • (%. I - ‘ .A r al to Qua i it : Ai lit" .- I S. to.. ..Sprat I i I 11 11 Mt ,,�...,�_- _...........-.�...----�--. i IL 60 SIM stlandl•• fa I r ,•w••• t A / la— il I Ni. 4 4— • x , is , tb ir se : 1 I Cill,„ t , i , „..1i 1 M. ss..a... • f�it r i. . of .0 r v e -'1 •4116•401k Sallie -4 ell • .T i f, 1 \.. 4i''. d ?II kV jj tei l.^ ties g 4, 11 9, 1 I • r i 1 r , i l_........§P Ill O. ant -tir T ._ ... i 1 Illb &aka ..4% 1 i at lit w0M NSW ii 1 Li Palliall""inalthl "el 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 I HAVE READ AND UNDERSTAND THE PROVISIONS AND REQUIREMENTS OF WELD COUNTY CODE CHAPTER 7,INCLUDING,BUT NOT LIMITED TO, SECTION 7-8-10,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. , ,.._%_____ ......F, loir)et4s) Signatur f Applicant Title Dat SUBSCRIBE AND FF RMED BEFORE ME THIS 3)44 DAY i'�� E - ,20 1 5 ,IN THE COUNTY OF APA MS ,STATE OF COLORADO. • NICKIE MAIU.ET NOTARY PUBLIC STATE OF COLORADO Signature of Notary NOTARY ID 20077 MY C0rrMSS"EWIRES MAY 23,2019 My Commission expires: CJ / 23 /24 19 Page 7 V1/4` ,A 1 DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT 1555 N. 17`h Avenue ` i r l - i Greeley, CO 80631 4' - Public Health Web rtty 1twv,tw co weld co us/Departmentsh ealthEnvironment/index him; Health Administration Public Health S Clinical Environmental Health Communication, Emergency Preparedness Vital Records Services Services Education&Planning S Response 1 N 1 Y re* 9 i 394 Ex Tele 970 304 6420 Tele 970 304 6415 Tele 970 304 6470 Tele 970 304 6429 •_ Cj O --2 Fa. 9%2 304 641 Fax 970 3046416 Fax 970 304 6411 Fax 970 304 6452 Fax 970 304 6469 O.r.:•r-•cn Together elh the communities we serve we are workm•7 to make Weld County the het e.cest place to Ova learn,won,and play October 23,2015 David Bressler Chair Weld County Emergency Medical/Trauma Service Council Via email: Dave.Bressler@ibannerhealth.com SUBJECT: 2016 Banner Hcalth/NCMC Paramedics EMS Application NOTICE OF EMERGENCY MEDICAL SERVICES LICENSE APPLICATION TO THE WELD COUNTY EMERGENCY MEDICAL/TRAUMA SERVICE COUNCIL The Weld County Department of Public Health and Environment has received and is in process of reviewing an Emergency Medical Service License Application from Banner Health/NCMC Paramedics. Attached to this document are the Ambulance Service License Application.and Maps of its proposed Service Area. On behalf of the Board of County Commissioners, the Department is requesting the Emergency Medical/Trauma Service Council review the attached documents in accordance with Section 7-2-100.B.5. of the Weld County Code (enumerated below). The Department will forward your recommendation to the Commissioners. Below are the most applicable portions of the code: Weld County Code,7-2-100.B.5 The recommendation of the Weld County Emergency Medical/Trauma Service (EMITS) Council as to whether or not the issuance of the license will contribute to an efficient, effective, and coordinated emergency medical response to residents of the County. The EM/TS Council shall also provide: a. Recommended Service Area. b. Recommended Tier of License. Weld County Code,7-2-10. No person shall provide or operate an ambulance service publicly or privately in the County unless that person holds a valid license to do so issued by the Board of County Commissioners,except as provided in Section 7-2-80 below, The fee for said license shall be set by separate ordinance. The license shall issue only in the following tiers of service: Tier I: Licensurc authorizing for Primary Care, as defined in Section 7-1-30 of this Chapter. 'Pier II: Liceusure authorizing for transports of patient(s)to and from licensed medical facilities. This licensure does not provide for Primary Care, as defined in Section 7-1-30 of this Chapter. Tier III: Licenwurc authorizing for Standby Service, as defined in Section 7-1-30 of this Chapter. A The Board of Counts Commissioners reserves the right to amend these rules and regulations and any other individual conditions of licensing as applied to any particular license,as needed in keeping with its legislative function and in order to implement the policy of the State of Colorado that the regulation and control of ambulance licenses is in the exclusive purview of the boards of county commissioners. Persons or firms seeking application and approval of any ambulance license under this Chapter acknowledge that Weld County may contract with specific ambulance service provider(s) which will serve the emergency ambulance need of Weld County and participating inun icipalities Please forward the Councils recommendation to the Department including minutes of the EMS Council meeting pertaining to this application. Please do not hesitate to call me should you have any questions. Sincerely. Kevin Antuna Environmental Health Specialist Environmental Health Services d __ m. _ Recommendation of the Weld County Emergency Medical/Trauma Service Council for: Banner Health/NCMC Paramedics As required in Section 7-2-100.11.5., the EMTS Council should review the application to assess as to whether the ambulance service will contribute to an efficient,effective, and coordinated emergency medical response to residents of the County? Please include any findings related to response time, coordination with other ambulance services, location, service area, etc. that is the basis for the Council's recommendation: FINDING#1: Banner NCMC Paramedic Sem ices is in compliance with their contracts in Weld County for emergency and routine response. There have been no issues reported to the EMTS Council concerning the service provided to the citizens and visitors to the Weld County Service area. FINDING#2: Banner NCMC Paramedic Sen ices has provided assistance to all agencies that have requested assistance throughout the 2015. There have been no issues reported to the EMTS Council concerning mutual aid requests. FINDING #3: FINDING #4: Recommended Level of Service: Tier 1 Tier 2 Tier 3 Recommended Service Area: As listed on the application. Other EMTS Council recommendations or comments: Recommend approval of a Tier 1 License as requested for the service area listed on application. Recommendation By: "`'' ~___ Date: 11-18-2015 Banner Health/NCMC Paramedics Ambulance Service License Application Date of Application: 10/21/2015 Name of the Ambulance Service: Banner Health/North Colorado Medical Center Paramedic Services Owner: Name Banner Health/North Colorado Medical Center Address: 180116th Street. Greeley,CO. 80631 Phone Number: (970)810-2435 Assistant Chief: Name Mitch Wagy Address: 1121 M Street. Greeley,CO. 80631 Phone Number: (970)810-2435 Medical Director: Name Dr.Rob Lowe Address: 1121 M Street. Greeley,CO. 80631 Phone Number: (720)317-9964 For Office Use Only: Name and address of each stockholder or partner owning 10%or more of the outstanding stock of the company or having more than a 10%ownership interest if applicable: Not Applicable. What area of your County will be served by this company? Please attach a map indicating the service area. • Map#1. • Map#2. All of the Weld County Service area with the exception of the following cities or towns: • Dacono. • Firestone. • Frederick. • Johnstown. • Lochbuie. • Milliken. • Severance. • Windsor. • Southeast Weld. I / .. Weld ..- . I i 41s. ._. ... 1 ,,Y• _— - -_ ...�,._ • . .. - ® WELD COUNTY M1}wV�Y '"" ,.....�� s., ',1' Grreiey 40 twsn t y W- :. Vintuoat2 How many ambulances do you operate? 14 Stations: How many stations do you have? 5 Indicate the location and description of the stations from which these ambulances will operate. If there are more than two locations,attach a separate sheet with the above information: Location#1 Address: 1121 M Street. Greeley,CO. 80631 _ Phone Number: (970)810-2438 Location#2 Address: 3401 S. 11th Avenue. Evans,CO. 80620 Phone Number: (970)810-2452 Location#3 Address: 2000 70"'Avenue Phone Number: (970)395-2690 Location#4 Address: Gilcrest Fire Department: 14679 WCR 42. Gilcrest,CO. 80651 Phone Number: _ (970)737-2966 Location#5 Address: Fort Lupton Fire Department: 2999 9h Street. Fort Lupton,CO. 80621 Phone Number: (970)392-2446 As required in Section 7-3-30 of the Weld County Code Ordinance and Chapter 4 Section 6 of the CDPHE Emergency Medical and Trauma Care System regulations, as of the date of the application, are you in compliance with the minimum data collection and reporting of transportation and/or treatment of patients: ht__.ps://www.colorado,gov/cdpheiregulatiSns EYes ❑No As required in Section 7-3-40 of the Weld County Code and Chapter 3 Section 3 of the CDPHE Emergency Medical Services regulations, as of the date of the application, are you in compliance with the reporting requirements of the agency profile: gYes ❑No Please read carefully: Sec. 7-2-10 License for Ambulance Service. No person shall provide or operate an ambulance service publicly or privately in the County unless that person holds a valid license to do so issued by the Board of County Commissioners,except as provided in Section 7-2-80 below. The fee for said license shall be set by separate ordinance. The license shall issue only in the following tiers of service: Tier I: Licensure authorizing for Primary Care, as defined in Section 7-1-30 of this Chapter. Tier II:Licensure authorizing for transports of patients that originate in Weld County from licensed medical facilities. This licensure does not provide for primary care, as defined in Section 7-1-30 of this Chapter. Tier III: Licensure authorizing for Standby Service, as defined in Section 7-1-30 of this Chapter. Level of Service Requested: Tier I 0 Tier II 0 Tier III I have attached the following documents to this application: psok 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 and date of birth 2. The highest level of certification, 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. cgt 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. btip://www.ha nnerhea I t h.co n tiLocat ions/Colorad o/North+Colorado+Meth ca l+Ccnter/Pru grams+and Services/Paramedics/Medical+Professionals/Medical+Protocols.htm ixf A current copy of the ambulance service's training standards in accordance with the requirements approved by the ambulance service's medical director that includes proof of a medical continuous quality improvement program. All training must be through a state- certified emergency medical services training center. ❑ A list of ambulance agencies, fire departments, special districts and other EMS providers with which the applicant has mutual aid agreements, or: kAt this time our agency does not have mutual aid agreements with other ambulance agencies, fire departments, special districts or EMS providers. kiA current copy of the ambulance service's pharmacological agents and delivery devices per medical director protocol. 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 1 HAVE READ AND UNDERSTAND THE PROVISIONS AND REQUIREMENTS OF WELD COUNTY CODE CHAPTER 7,INCLUDING,BUT NOT LIMITED TO, SECTION 7-8-10,WHICH ENCOURAGES ALL LICENSED AGENCIES PROVIDING EMS RESPONSE 1N 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 CONS 31TUTES GROUNDS FOR LICENSE REVOCATION AND POSSIBLE CRIMINAL 6 PROSECUTION. / _ t w /' S(nurc of wattt Title Date SUBSCRIBED AND AFFIRMED BEFORE ME THIS 15.4`' DAY (k,rtolpe.e ,20 l S ,IN THE COUNTY OF _ h-)4.-Lc( _ STATE OF COLORADO. I TARE Notary Mcowed.EI O1.11.n _ ¢.. I swim o1 CObA Signature of Nota Notary ID 201 nm:4n �-7 I My Commission Ex Iris WI 27 2017 My Commission expires:_ g,. / 2-7 /_O-O ll Page 6 Hello