BAYTOWN FIRE DEPARTMENT 201 E. Wye Drive Baytown, TX

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1 Shon Blake Fire Chief Rick Davis City Manager Permitting Procedure for Private Ambulance Service The proposed ambulance permitting procedure is essentially a form of registration for private ambulances wishing to operate in the City of Baytown. The objectives of the new permitting procedure are: To ensure that the Fire Department is aware of all private ambulance services operating in the City, by requiring the private ambulance companies to register with the Fire Department. To ensure that all private ambulance services operating in the City have been appraised of the City ambulance ordinance, by distributing and reviewing the ordinance at the time of registration. To ensure that the Fire Department has contact numbers and names for the private ambulance service, so that the Public Safety Communications Division may call the service in the event of an emergency and so that the Fire Department may contact the service in the event of a citizen complaint or for an inspection. The ordinance will not attempt to establish competency or qualifications of the private ambulance service or its personnel. The Fire Department will respond to any complaints by citizens or visitors regarding the performance of a private ambulance, and will perform annual inspections of private ambulances to ensure minimal compliance to State regulations. The permitting process will not impact ambulance services that transport patients TO Baytown. Ambulance agencies that pick up patients within the City Limits must be permitted. Enforcement of the private ambulance permitting process will be the responsibility of the Fire Department. The ordinance will not permit or attempt to track the individual personnel employed by the private ambulance service. It is the responsibility of the private ambulance service to maintain compliance with all Texas Department of State Health Services regulations, including staffing requirements. At the time of registration, the private ambulance service must provide the following: Name, address and phone numbers of principle company officers Name, address and phone numbers of Local office Name, address and phone numbers for ambulance dispatch Name, address and phone numbers of the EMS Medical Director Number of units that will be permitted to operate in the City of Baytown Level of care that the service will provide (by TDSHS definition) Proof of public liability and property damage insurance with coverage limits Proof of current, valid TDSHS EMS Provider Permit The proposed fees for permits will be as follows: Application fee (plus one ambulance) $ Each additional ambulance $ Permits renewal January of each Calendar Year

2 THE APPLICATION PACKET ALONG WITH THE APPROPRIATE FEE SHOULD BE SUBMITTED TO THE BAYTOWN FIRE DEPARTMENT EMS DIVISION OFFICE. THE ADDRESS IS: Baytown Fire Department Medical Transfer Permit 201 E Wye Dr. Company Name: Street Address: Mailing Address: City: State: ZIP: County: Owner Name: Director Name: Address: Medical Directors Name: Fax: Mailing Address: City: State: ZIP: Address: Fax: Permit Fees: Make Check or Money Order Payble to City of Baytown Fire Department $ application fee (includes one ambualnce) $ for each additional ambulance Number of Vehicles BLS ALS Total Vehicles BLS with ALS Capability BLS with MICU Capability ALS with MICU Capability MICU I, submit this application in behalf of the above named firm, to the City of Baytown. I hereby afirm and declare that all information submitted on this form is true and correct. It is understood that false statements of information on this applicaiton maybe considered as sufficient cause for revocation or denial of permit. I shall also notify the City of additions(s) or substitutions(s) of cehicle(s), change in provider name or ownership, change in medical director, permanene or long term change in level of service, and any other responsibility as defined by ordinance during the permit period, Signature of Applicant: Signed: Notary Statement SUBSCRIBED AND SWORN TO BEFORE ME, to certify which witness my hand and seal of office the day of, 20. NOTARY PUBLIC,In and for the State of Texas My Commission Expires

3 THIS COMPLETED FORM IS TO BE FORWARDED WITH MEDICAL TRANSFER SERVICE APPLICATION This form is for the medical director to list ALS and/or MICU equipment the provider will need to perform in a proficient manner. The medical director must consider all types of patients the provider might encounter. The ambulance will be inspected according to this list and the EMS Vehicle Inspection Report. This list must match protocol specifications. (Attached additional pages if needed). Firm Name: IV Catheters Medical Director Name: Medications Size (gauge & Length) Amount Type Dosage Amount IV Solutions Type CC's Amount Advanced Airway Equipment Description Size Amount Specialized Equipment (i.e. 12-Lead, Pulse Oximeter, EZ-IO) Amount I verify that the above proficiency list has been prepared to conform with quality improvement plans and patient census assessments for the Medical Transfer Service named in the accompanying application Signature of Medical Director

4 Baytown Fire Department 201 E Wye Drive Baytown TX Firm Name: Unit # Make Year LIC# Vehicle Identification Number (VIN) Category* Type Location of Vehicle Category is the level of care of each unit: BLS, BLS/A, BLS/M, ALS, ALS/M, MICU or RES (Reserve) Permit Fees: Make check or money order payable to: $ Permit fee (includes ONE ambulance) $ for each additional ambulance City of Baytown Submit this form and payment to: Fee Exemptions: None Baytown Fire Department Emergency Medical Services Medical Transfer Service Permit 201 E Wye Drive I, submit this application in behalf of the above named firm, to the City of Baytown and request inspection of the vehicles described herein as EMS vehicles. I hereby affirm and declare that all information submitted on this form is true and correct. It is understood that false statements of information on this appication may be considered as sufficient cause for revoction or denial of permit. I shall also notify the City of addition(s) or substitutions(s) of vehicle(s), change in provider name or ownership, change in medical director, permanent or long term change in level of service, and any other responsibility as defined by ordinance during the permit period. Signature: Person to be Contacted: :

5 Firm Name: DSHS Provider #: Unit # Make: Tag: Vin: BLS ALS MICU Type I II III Other: Medical Equipment - All equipment is required on the ambulance upon inspection. The quanity and type of some ALS/MICU equipment should be listed on the attached Medical Director Autoorized ALS/MICU Equipment Form. All equipment specified on the form should accomodate the needs of all types of patients, including infants and children. Item BLS Equipment Y N Item Y N 4 rolls of adhesive tape 1 portable suction unit (no foot pump or buld type) 12 triangular bandages Bag valve mask resuscitators (adult, child,infaant 4 sterile burn sheets Oral airways (sizes for adult, child, infant) 2 bandage shears Oxygen deliveryt devices for adult and child 1 sealed OB kit with non-porous infant insulator 2 pordable oxygen cylinders 1 penlight 1 portable oxygen regulator Multilevel stredtcher (2 clean sheets and blankets) Piped in oxygen with regulator (M or H cylinder) BLS Protocols Extrication Collars (sizes for adult, child, infant Extremity splints for all extremities ALS Equipment Medical Protocols with types and quanities of IV solutions, iv catheters, laryngoscopes, endotracheal tubes, other advanced equipment and specialized Traction splint(s) to accommodate adult and pedi Spine boards -1 long, 1 short with straps equipment IV solutions, IV catheters and/or IO's listed Sphygmomanometers (sizes for adultm child, infant) 50% Destrose 1 stethoscope Advanced airway equipment as listed 2 mulit-trauma dressings Specialized equipment as listed 60 sterile gauze pads 6 occlusive dressings MICU EQUIPMENT Cardiac Monitor/defibrillator 12 soft roller adhering bandages Medications and other equipment as listed REGULATED WASTE AND INFECTION CONTROL SUPPLIES - SAFETY AND MECHANICAL EQUIPMENT Puncture resistant sharps container 3 road flares/warning triangles Red "Biohazard" bag Glashlight 1 box of latex or rubber gloves or equivelent Fire Extinguisher 2 pair protective goggles No smoking signs (cab and patient care area) Emergency lights and siren Current motor vehicle inspection sticker Emergency Response Guide Book Name of service on sides of vehicle Air conditioner/heater two way radio or cellular phone Comments: Inspection Results: Approved Disapproved On this date, the above described vehicle has been inspected in the presence of a firm representative and the items and conditions are indicated. A copy of this form will be retained by the firm representative. Inspector Firm Representative