Office Use
Date Received:
Flat Fee Invoice Sent:
Payment Received:
Meeting:
Added to checklist:
APPLICATION FOR REACCREDITATION
1.
Name of medical transport service:
2.
Mailing Address:
3.
Name and Address of Hospital (if hospital affiliated):
4.
Telephone: Business:
FAX:
5. Description of Service: (Check each that applies to your service)
Types of Service
Transports Request Accepted for - RW
RW (ALS)
Burns
RW (Critical Care)
Cardiac
FW (ALS)
IABP
FW (Critical Care)
Trauma
Ground (BLS)
Pediatric (PICU)
Ground (ALS)
High Risk OB
Ground (Critical Care)
Adult
Medical Escort (Basic Care)
Neonatal
Medical Escort (Advanced Care)
6.
Size of the Service:
Total number of transports in most recent fiscal year- RW:
Total number of bases:
located)
FW
FW:
G
G:
(A base is defined as any place aircraft/ambulance and medical crew are
Total number of dedicated aircraft/ambulance(s):
(Dedicated aircraft/ambulance(s) are used for more
than 1 transport per month for any consecutive six month period)
7.
Air Taxi Certificate Holder and Ambulance Owner/Operator:
Rotorwing - FAA Cert #:
(Company Name):
(Address):
Fixed Wing - FAA Cert #:
(Company Name):
(Address):
Ambulance:
8.
(Owner/Operator):
Principle Administrative Contact:
Contact phone number:
Program Website:
Name:
Title:
Contact email address: