Agenda 01/14/2020 Item #16E3 (COPCN w/Care Med Transportation)Proposed Agenda Changes
Board of County Commissioners Meeting
January 14, 2020
Move Item 16C3 to Item 11F: Recommendation to offer residents grant funded, curbside bear-
resistant solid waste containers, as defined in the adopted BearWise ordinance, at a subsidized cost
with deployment provided by Waste Management, Inc., of Florida through a Memorandum of
Understanding. (Commissioner Saunders’ request)
Move Item 16D1 to Item 11G: Recommendation to adopt a Resolution repealing all previous
resolutions to increase Pickleball membership fees and to establish a fee for non-residents in the
Collier County Parks and Recreation Division Facilities and Outdoor Areas License and Fee Policy.
(Commissioner Solis’ request)
Continue Item 16E3 to the February 25, 2020 BCC Meeting:
Recommendation to approve a Certificate of Public
Convenience and Necessity for non-emergency inter-facility
Basic Life Support (BLS) ambulance transports to Care
Med Transportation, LLC, for the purpose of providing
post-hospital and inter-facility medical ambulance transfer
services. (Staff’s request)
Withdraw Item 16E5: Recommendation to award Invitation to Bid #19-7652, Gillig Bus Parts, to
Gillig, LLC, for the supply of Original Equipment Manufacturer (“OEM”) and non-OEM parts to
maintain and repair the County’s bus fleet. (Staff’s request)
Note:
Item 16C4: Recommendation to surplus County-owned property located at 343 Saint
Andrews Boulevard, advertise the property for sale pursuant to the provisions outlined in
Section 125.35(1)(c), Florida Statutes, and set a minimum bid of $126,583 $111,500.
01/14/2020
EXECUTIVE SUMMARY
Recommendation to approve a Certificate of Public Convenience and Necessity for non -emergency
inter-facility Basic Life Support (BLS) ambulance transports to Care Med Transportation, LLC,
for the purpose of providing post-hospital and inter-facility medical ambulance transfer services.
OBJECTIVE: To proceed in the best interest of the public health, safety and welfare by granting
a Certificate of Public Convenience and Necessity-Class 2, Basic Life Support (BLS) post-hospital, inter-
facility ambulance transports to Care Med Transportation, LLC, hereinafter referred to as “Care Med.”
CONSIDERATIONS: On June 26, 2019 the Collier County's Bureau of Emergency Services received an
application from Care Med Transportation, LLC for a Certificate of Public Convenience and Necessity
(COPCN) to provide Basic Life Support (BLS) Class 2 (post -hospital inter-facility medical transfer
services) ambulance transportation within Collier County. On October 9, 2019, staff and the Emergency
Medical Authority (EMA) reviewed the information submitted and deemed the application as
complete and recommends that the COPCN be granted for one year.
It is the opinion of the Bureau of Emergency Services that this service is necessary and practical to
provide an additional medical transportation service(s) to patients being transferred from hospital-to-
hospital, hospital-to-home, or transport for clinical procedures, etc. It is reasonable to expect the services
of an additional provider will assist in the anticipated future demands of the fast pace of the expanding
number of nursing homes, rest homes and skilled care facilities as well as population growth. The
expansion of additional non-emergency ambulance vehicles should reduce wait times for facilities and
their patients during discharge, and further reduce the calls for non-emergency service transport placed
upon Collier County EMS.
Care Med, operating as a BLS provider of inter-facility transports, has submitted its medical protocol and
it has been reviewed by Collier County EMS staff. Care Med has its own medical director who will
cooperate with the County’s Medical Director as needed.
Neither Collier County, nor the Sheriff’s 911 Center, receive or track such calls for non-emergency inter-
facility service made between a hospital, nursing home, or doctor’s office, etc. All estimates for calls for
service are compiled from data provided by Care Med Transportation, LLC, and from the infrequent
request for inter-facility transports to Collier County EMS when 911 is contacted for the dispatch of a
Collier County EMS ambulance.
Staff’s broad estimates suggest that approximately 6,000 transports are typically handled by a Class 2
Certificate holder on an annual basis from current facilities in Collier County. A broad estimate of the
over 500 beds reported in permitting for local construction could generate an additional 100-200 annual
convalescent transports in the near future as additional facilities become operational and local population
and seasonal increases occur. Staff does not have information as to the timing of bed’s and facility
openings as referenced above. As a result of the market place nature of the additional facilities and beds,
the convalescent transport estimates are rudimentary at best. The County has no obligations to
compensate a private ambulance provider for any services, nor does the County receive any revenue from
service delivery by a private ambulance provider.
Should the Board approve an annual Class 2 Certificate of Public Convenience and Necessity to Care
Med Transportation, LLC, the following provisions of the Certificate are recommended requirements:
1. This current COPCN application to expire on January 10, 2021.
16.E.3
Packet Pg. 1621
01/14/2020
2. Care Med Transportation’s COPCN shall be required to be renewed annually. Its renewal
application is to be received no later than 90 days prior to its expiration.
3. Care Med Transportation will be required to work closely with Collier County EMS,
Collier County Sheriff's 911 dispatch personnel, local licensed facilities, and other responders
to ensure that their entry into local and regional inter-facility ambulance transportation is
properly coordinated and services appropriately represented. Collier County Bureau of Emergency
Services and or its EMS Division shall be allowed to conduct any reasonable inspections or site
visits and receive in a timely manner any statistical call volume information needed to evaluate
services, monitor complaints and address any quality of care issues.
FISCAL IMPACT: This redistribution of non-emergency transports to Care Med Transportation,
Ambitrans and Just Like Family-Concierge Medical Transport on Collier County Emergency Medical
Services, would allow for increased utilization of Collier County EMS for the escalating emerge ncy
scene calls for service. Staff deems the increase in emergency vehicle availability for its core mission
worthy of this effort. There is no increase to the Collier County EMS budget for this Class 2 COPCN if
approved. In order to recognize the $250 application fee from Care-Med, a budget amendment is
necessary.
GROWTH MANAGEMENT IMPACT: There is no Growth Management Impact resulting from
this action.
LEGAL CONSIDERATIONS: Regarding the consideration of this item, Ordinance No. 04-12,
as amended, Section 7 states:
“The Board of County Commissioners shall not grant a certificate unless it shall find, after public
hearing and based on competent evidence that each of the following standards has been satisfied:
A. That there is a public necessity for the service. In making such determination, the Board of
County Commissions shall consider, as a minimum, the following factors:
(1) The extent to which the proposed service is needed to improve the overall Emergency
Medical Services (EMS) capabilities of the County.
(2) The effect of the proposed service on existing services with respect to quality of
service and cost of service.
(3) The effect of the proposed service on the overall cost of EMS service in the
County.
(4) The effect of the proposed service on existing hospitals and other health care
facilities.
(5) The effect of the proposed service on personnel of existing services and the
availability of sufficient qualified personnel in the local area to adequately staff all
existing services.
(6) That the applicant has sufficient knowledge and experience to properly operate the
proposed service.
B. That, if applicable, there is an adequate revenue base for the proposed service.
C. That the proposed service will have sufficient personnel and equipment to adequately
cover
the proposed service area.”
Ordinance No. 04-12, Section 8 provides:
16.E.3
Packet Pg. 1622
01/14/2020
“In making the determinations provided for in Section 7 above, the Board may, in its sole discretion,
appoint a Hearing Officer to hold a public hearing and to make factual findings and conclusions as a
result of the hearing. Should a Hearing Officer be appointed, said Hearing Officer shall render a written
report to the Board within 30 days of the hearing, which report shall contain the officer's findings and
conclusions of fact, and a recommended order. The findings and conclusions of fact shall be binding
upon the Board, but the recommended order shall be advisory only.”
A copy of the application is included with this Executive Summary. Copies of staff response and
protocols are available for examination in the office of the Board of County Commissioners. This item is
approved for form and legality and requires a majority vote for Board action. JAB
RECOMMENDATION: To approve and authorize:
1. A Certificate of Public Convenience and Necessity for Care Med Transportation, LLC, Inc
for up to (2) two ambulances under this permit;
2. The Chairman to execute the Permit and Certificate;
3. A Budget Amendment to recognize and appropriate the $250 application fee.
Prepared by: Dan E. Summers, Director, Bureau of Emergency Services
ATTACHMENT(S)
1. [Linked] Full application (PDF)
2. Care Med Permit CAO Approved (PDF)
3. Care Med Certificate CAO Approved (PDF)
4. Care Med VIN CAO Approved (PDF)
16.E.3
Packet Pg. 1623
01/14/2020
COLLIER COUNTY
Board of County Commissioners
Item Number: 16.E.3
Doc ID: 11022
Item Summary: Recommendation to approve a Certificate of Public Convenience and Necessity
for non-emergency inter-facility Basic Life Support (BLS) ambulance transports to Care Med
Transportation, LLC, for the purpose of providing post-hospital and inter-facility medical ambulance
transfer services.
Meeting Date: 01/14/2020
Prepared by:
Title: Executive Secretary – Emergency Management
Name: Kathy Heinrichsberg
12/02/2019 4:56 PM
Submitted by:
Title: Division Director - Bureau of Emer Svc – Emergency Management
Name: Daniel Summers
12/02/2019 4:56 PM
Approved By:
Review:
Emergency Management Daniel Summers Additional Reviewer Completed 12/09/2019 10:01 AM
Administrative Services Department Paula Brethauer Level 1 Division Reviewer Completed 12/10/2019 2:01 PM
County Attorney's Office Jennifer Belpedio Level 2 Attorney of Record Review Completed 12/12/2019 9:50 AM
Administrative Services Department Len Price Level 2 Division Administrator Review Completed 12/12/2019 12:23 PM
Office of Management and Budget Laura Wells Level 3 OMB Gatekeeper Review Completed 12/12/2019 3:21 PM
County Attorney's Office Jeffrey A. Klatzkow Level 3 County Attorney's Office Review Completed 12/13/2019 9:07 AM
Budget and Management Office Mark Isackson Additional Reviewer Completed 12/16/2019 10:51 AM
County Manager's Office Sean Callahan Level 4 County Manager Review Completed 01/02/2020 3:09 PM
Board of County Commissioners MaryJo Brock Meeting Pending 01/14/2020 9:00 AM
16.E.3
Packet Pg. 1624
16.E.3.b
Packet Pg. 1625 Attachment: Care Med Permit CAO Approved (11022 : Care Med Transportation, LLC)
16.E.3.c
Packet Pg. 1626 Attachment: Care Med Certificate CAO Approved (11022 : Care Med Transportation, LLC)
16.E.3.d
Packet Pg. 1627 Attachment: Care Med VIN CAO Approved (11022 : Care Med Transportation, LLC)
L
JUN 262019
Cdller County
ncy Maid
T-rans�vortation� LLC
Phone number: (239) 599 - 5606
Fax: (239) 599 - 5607
3510 Kmft Rd, Suite 200
Naples, FL 34105
Report for
Collier County COPCN Application As required By DOH for Initial
Licensure As An EMS Provider
February, 2019
"�.
Thw* you for your Om.
RespedAdly YOM,
Ner"-Apenor. RN, CEO.
Care Med Transportation LLC -Collier County COPCN Application,
Section 50-55 Procedure For Obtaining a Certificate
Table Of Contents
Section 1 Letter by Nerlyne Saintyl-Agenor, RN, CEO
Section 2 Collier County Census Report and Collier County Area To Be Serviced
Section 3
Primary market to be serviced, including the hospice population
Section 4
Current, anticipated demand for the service and boundaries of territory to be served
Section 5
Brief overview of staffing levels hours of operation
Section 6
Name, Age, Address of the owner. Background, skills and experience of the applicant
Section 19
(Please see attached resume of the owner/applicant).
Section 7
Quality Assurance, Quality Control & Quality Improvement Measures; & Continuing
Section 21
Education For Staff Members
Section 8
Ambulances' description and number of vehicles to be used
Section 9
Headquarters' address and of other substation
Section 10
Training and experience of the applicant
Section 11
Billing operations, office hours, provider contracts, and medical director engagement
Section 12
Name and addresses of three Collier County residents acting as references for the
Applicant and experience of the applicant
Section 13
Schedule rates
Section 14 Financial Compilation of profit and loss for the past year, 2018
Section 15 Deteriorating patient condition enroute, or discovery of patient with multiple injury or
Illness with rapid declining stability
Section 16 Oxygen, AED Protocols, Medications' Protocols, Transfer & BLS Medical Protocols
with written approval by Dr. Robert Tober Chief Collier County EMS Medical
Director and Care Med's Medical Director.
...r
"Remain Blessed"
(Please see signed BLS medical protocol Packet)
Section 17
Certificate Of Insurance, Projected Workers' Compensation Insurance, Sunbiz
Registration Of Corporations & Collier County Business Tax Receipt
Section 18
Medical Director's CV. FL Medical License and Job Statement
Section 19
Reference Letters
Section 20
Interfacility Narrative Form & Signed Necessity Form For BLS Transfer
Section 21
DNRO Transfer Form, Consent protocol for Code Status During BLS transferring
Section 22
State BLS Equipment and Supply List & References
Section 23
Communication Protocols for Care Med BLS Ambulance Non -Emergency Medical
Interfacility Transfer
...r
"Remain Blessed"
Care Med Transportalfon LLC.Collier County COPCN Application,
Section 50.55 Procedure For Obtaining a Certificate
m
Section 1
Letter By Nerlyne Saintyl-Agenor, RN & CEO
MA
Section 11,
r�
i
rtation, LLC
Phone number. (239) 599 - 5606
Fax: (239) 599 - 5607
nerlynesaintyl@caremedtranportaUonlic.us
3510 Kraft Road, Ste 200
Naples, FL 34105
Dear Chairman,
Members Of the Collier County Board
and Director Of the Collier County EMS Department Mr. Summers,
I am reaching out to you to request your assistance in obtaining a COPCN in order to apply for
a BLS ambulance license to allow us to provide interfacility transfer for patients who require
oxygen during transportation; which is a higher level of transport that requires a licensed
healthcare professional to be in the ambulance. We would like to incorporate this additional
service to Care Med in order to assist and grow with the community at large. It is worth noting as
the registered nurse and CEO of Care Med, I will also be able to provide this service in lieu of
an EMT as confirmed by the Florida department of health.
Care Med Transportation LLC was established in 2014 and has been serving and growing with
the Collier community; meeting many transportation needs for numerous clients. During
transportation, we at Care Med provide compassionate care and support to every patient as well
as their loved ones.
One by one, one patient at a time, one loved one at a time.
It has been a great pleasure partnering with other facilities In the community to provide safe
transportation to all the patients we transport; especially those patients who have greater need
during transportation, such as the acutely III and hospice patients.
As the CEO of Care Med Transportation LLC with over 15 years of nursing and over 5 years of
hospice experience, I have been able to use my nursing skills and hospice knowledge and
experience to help patients and their loved ones during the transportation process.
Section 1-1
Avow Hospice, has been one of our major partner. As a hospice nurse, I have been Blessed
with the opportunity to not only care for the hospice population, but to also transport them during
their most vulnerable moments. We have been transporting hospice patients for over two years
and ongoing, and look forward to continue doing so for many, many more years.
From 2012 through 2019, according to public records the census/population was 321,520
people. As the county is evolving and growing research has shown the current population is
approximately 372,880. Clearly, Collier county is growing and will be in need for greater
assistance medically, given the opportunity to obtain the BLS ambulance license,it will benefit
our community greatly (Please see the attached projected population growth as evidenced by
research). Additionally, I have dealt with the hospice population who is in dire need of reliable
and swift transportation, especially when they are experiencing acute distress, such as
increased pain, difficulty breathing,terminal restlessness, etc... Care Med would like to be front
and center in transporting all patients, especially the hospice patients.
See enclosed report in this packet with all required state documents, including my resume for
Care Med, the rates, a check for $250, current insurance for Care Med, Workers' compensation
prospective insurance.
I would like to thank you for reviewing this report and I am looking forward to hearing from you
very soon.
Should you have any question or concern, please contact me via the telephone at (239)
599-5606 or via email at nerlynesaintyl@caremedtransportationllc.us
Thank you for your time and consideration,
Respectfully yours,
Nerlyne Saintyl-Agenor, RN, CEO.
Section 1-2
0
A4
1___1 Transportation,
Phone number. (239) 599 - 5606
Fax: (239) 599 - 5607
3510 Kraft Rd, Suite 200
Naples, FL 34105
LLC
Care Med Transportation BLS Ambulance Services
. Protocol
What is the difference between a BLS and ALS emergency transport?
Basic Life Support (BLS) is an emergency transport provided by certified Emergency Medical
Technicians (EMTs), can also provide non -emergent interfacility transport by certified EMTs.
Advanced Life Support (ALS) is provided when a patient is in more critical condition and a
paramedic is required to assist In the treatment of the patient before and/or during transport to
the emergency facility.
Care Med Transportation Basic We Support (BI -S) ambulances will only provide non -emergent
Interfacility -transfer and will be fully equipped and staffed by two highly trained Emergency
Medical Technicians (EMI's). Care Med Transportation will provide ambulance service 7 -days a
week, 24 -hours per day throughout Collier county. All BLS ambulances will be licensed and
Inspected by the Florida State EMS agency. We will use only the required ambulances by The
Florida Department Of Health with the 'KKK -A-1822• (Please refer to the next page as a
reference to the Florida Department Of Health -Emergency Medical Services Basic Life Support
Vehicle Inspection Report).
Section 1-3
CM
00*41
Transportation, LLC
Phone number. (239) 599 - 5606
Fax: (239) 599 - 5607
3510 Kraft Rd, Suite 200
Naples, FL 34105
As a BLS ambulance:
We will only transport patients who are stable medically and who need interfactransfer.
We will not transfer residential patients to the ER, except hospice ility
doctor. Hospice patients fall under the non patients as ordered by their
-emergent category of patients and have their own
medical guidelines set by medicare and the department of health.
We will not transfer pediatrics patients.
We will not transfer critical care. patients, which require at a minimum an ALS ambulance with a
registered nurse in the ambulance. We will not be ALS (Advan(d Life Support) certified.
We will not transfer acute cardiac patients in distress, which re�auire an ALS ambulance with a
paramedic In the ambulance. We will not be ALS certified.
We will not transfer patients with any Infusion. Such as blood, car IV. We will not be certified to
do so.
We will not have any narcotics In our ambulances, that will be against the DEA law.
We are applying for the BLS (basic life support) ambulance license
r Florida health protocol, and will ONLY have on board our ambulances the basic necessaryaent of
requirements for the safe inter -facility transfer of stable patients.
DEA
The Drug Enforcement Administration is a United States federal law enforcement agency under
the United States Department of Justice, tasked with combating drug smuggling and
distribution within the United States. Wiki�
Section 1-4
Transportation, LLC
Phone number. (239) 599 - 5606
Fax: (239) 599 - 5607
3510 Kraft Rd. Suite 200
Naples, FL 34105
Care Med Transportation Protocol For Continuation Of Oxygen
Therapy During BLS Transfer
According to the FDA. Oxygen is a medication and is prescribed by a doctor. Like any other
medication, oxygen must be used carefully. As with most medications, it is ordered by a doctor
to meet a patient's specific respiratory needs.
Oxygen therapy can be ordered to be administered via: Mask, Nasal cannula, non-rebreather
mask, etc... specific to each patient's needs.
DOH requires a health care professional to monitor any patient with oxygen therapy during
Interfacility transfer.
All patient transported by Care Med Transportation BLS ambulance service will continue the
same oxygen therapy during transfer as previously ordered by their treating/transferring MD; a
copy of that order will be needed during transfer and ordered by Care Med 's medical director
for continuation of medical care.
Section 1-5
Transportation, LLC
Phone number. (239) 599 -.,Z06
Fax: (239) 599 -,5607
3510 Kraft Rd, Suite 200
Naples, FL 34105
Example of Oxygen order form for continuation of care during Care Med
TransPortedon BLS services
Copy of treating/discharging MD oxygen therapy during treatment for c o inuation of oxygen
therapy during transfer. .EMS Initial 9
Oxygen at LPM
Diagnosis for continuation of oxygen therapy per treadngitransfeMng MD:
EMS # and signature:
Via: Nasal cannula
Mask
Non-rebreather
Trach
Section 1-6
u
U
Care Med Transportation LLC-Colller County COPCN Application,
Section 50-55 Procedure For Obtaining a Certificate
Section 2
Collier County Census Report and Collier County Area To Be Serviced
"Ra"n BI P'
Section 2
Care Med Transportation LLC -Collier County COPCN Application,
Section 50-55 Procedure For Obtaining a Certificate
Section 2
Colder County Census Report and Collier County Area To Be Serviced
According to the United State Ceara Bu mau, Collier county is continually growing.
(Please see attached census ngort from the US Census Bureau).
v Care Med will be servicing all of Collier county via BLS Non -Emergency Medical Interfacility Tnumfer
as requested. Such areas include Naples, Marco Island, Everglades City, Immokalee City, Ave Maria; etc.
"Remain BNssod"
Section 2-1
Bureau of Economics and Business Research, Florida Population Stuides, Bullo*in 1-7-7
Section 2-3
Projections of Florida Population by County.
2020-2045,
with Estimates for 2016
County
Estimates
and State
April 1. 2016
2026
2025
pro)ertions, April 1
w
2030
2035
2040
20;5
ALACHUA
257,062
Low
Medium
HighMed
252,800
265,500
252,500
275,200
252,100
283,100
250,800
290,300
248,900
246,400
278,000
295,400
312,100
328,900
296,700
362,700
BAKER
26,965
345,700
362,700
Low
Medium
High
262W
27,800
26,000
28,700
25•�
29,500
25A00
30,100
25,600
24,500
29,400
31,300
33,200
35,000
3,600
31,100
BAY
176,016
366,800
38,500
Low
Medium
High194,600
173,800
184,700
175,300
176,200
202,700
175,600
Y09,400
174,000
172,100
194,900
211,300
227,200
242,300
215,100
22Q700
BRADFORD
27,440
257,100
272600
Low
Medium
High
27,200
28,800
26,600
29,300
29'900
25,200
29,700
24,400
23,00
30,500
32,000
3 3300
34,500
29,900
30,1100
BREVARD
568,919
35,900
37,200
Low
Medium
Hi h
High
S72,500
595,700
583 500
625,500
592,900
9,200
596,300
666,300
597,700
596,200
616,900
661,800
704,000
741,200
681,700
696,100
BROWARD
1,854,513
777,800
815,100
Low
Medium.
High
1,865,100
1,940,700
1,790100
2,038,400
1,933,400
2,117,200
1,952,400
4182,300
1,962,300
1,969,800
2,010,100
2,156,800
2,295,600
2,426,900
2,237,900
2,290,800
CALHOUN
14,580
2,553,700
2,684,000
Low
Medium
High
14.000
14,900
13,800
15,200
13'500
15,400
13.200
15,600
12,800
12,500
15,700
16,600
17,400
18,100
18,900
15,900
CHARLOTTE
170,450
19.600
LOW
Medium
High
169,300
180100
171,900
,000
191000
174,000
200,400
174,700
174,400
173,400
190
207,300
224,300
208,400
241,000
215,600
222,100
CITRUS
143,054
257,700
274,700
Low
H Medium
g
141,300
148 400
166,000
142,000
154,500
142,700
159,600
143,500
141,500
140,000
155,300
176,400
163,800
186,300
167,100
170,000
CLAY
205,321
195,700
204,900
Low
Medium
High
209,500
223,400
218,700
244,200
226,400
262,100
232300
236,900
240,100
725,400
_
278,700
__
J-c�,5G�
294,100
308,3D0
COWER
350,202
,150,100
380,400
Low
Medium
High
359,600
379,200
376,600
413,000
391 S00
442,000
404,300
414,600
422,400
395,400
440,500
484,800
469,200
530,100
493,800
516,000
COLUMBIA
68,566
575'900
621,900
Low
MMedium
M h
9
67,700
71,100
67,800
73,700
67,800
75,600
67,500
66,900
66,000
74,500
79,300
83,900
77,600
88,300
79,100
80,300
DESOTO
35,141
9 2,600
96,600
Low
Medium
34,200
35,900
33,800
33,600
33,200
High
37,600
36,700
39,500
37,500
38,200
32,700
38,700
32,200
DIXIE
1fi,773
41,500
43,400
45,300
39,200
47,200
LOW
Medium
`--+ High
16,200
16,000
17,700
15,800
18,100
15,600
15'200
14,900
18,200
19,300
2Q400
18,400
21,400
18,700
18,00
22,400
23,4400
Bureau of Economics and Business Research, Florida Population Stuides, Bullo*in 1-7-7
Section 2-3
V
V
Care Med Transportation LLC -Collier County COPCN Application,
Section 50-55 Procedure For Obtaining a Certificate
Section 3
Primary Market To Be Serviced, Including The Hospice Population
"Remain Bhwwwr
Section 3
M
Care Med Transportation LLC -Collier County COPCN Application,
Section 50-55 Procedure For Obtaining a Certificate
Section 3
Primary market to be serviced, including the hospice population
Currently Care Med Transportation provides non -emergency medical transportation via
ambulette to the geriatric population, and anyone who is physically challenged and needs to be
transported via wheelchair or stretcher from one facility to the other; including the hospice
population. Using two staff members at all times during stretcher transportation.
Care Med will continue to service the geriatric population, the hospice population and anyone
over 18 years of age who needs BLS Non-Emagency Medical Inteifilcility Transfer.
"ROmain SWesod"
Section 3-11
�.J
Care Med Transportation LLC -Collier County COPCN Application,
Section 50"65 Procedure For Obtaining a Certificate
Section 4
Current, anticipated demand for the BLS service and the boundaries
of territory to be served
Section 4
Care Med Transportation LLC -Collier County COPCN Application,
Section 50-55 Procedure For Obtaining a Certificate
Section 4
Current, anticipated demand for the service and boundaries of territory to be served
There are currently no BLS ambulance services in Collier County. There are two private
companies providing ALS ambulance services, with BLS sub category ambulance services. By
becoming a Collier County BLS ambulance service company that will allow the ALS certified
companies:
• To focus on the high acuity patients needing transfer from one facility to another.
• Decrease patients' costs for an ambulance company by allowing them to have the proper
choice on ambulance company based on their medical transfer needs.
• Given hospice patients who need oxygen the choice to be transported by certified
medical professionals like some patients and loved ones have been requesting.
• Prevent discharged hospital patients to have to wait for a two to three hour delay before
they can be transported out of the hospital because the other ALS ambulance companies
already have a waiting list of patients to be transported out of the hospitals.
• Hospice patients will no longer have to wait for a two hour delay before their comfort
measures can be met during their dying process because they can not be transported in a
timely manner to their dying place of choice because of the availability of an ambulance
service. A hospice patient who only needs oxygen can safely be transported by a BLS
ambulance service with two EMS on board, sometimes if death is imminent loved ones
have been allowed to travel with the patient so they can be present during the patient
transition into their next journey.
•
"Remain Blessed"
Section 4-1
u
Care Med Transportation LLC -Collier County COPCN Application,
Section 50-55 Procedure For Obtaining a Certificate
• There will be a decrease in patients waiting on an ambulance stretcher in the ER because
of room availability; if patients can be discharged in a timely manner then admitted
patients in the ER can be transferred to their admitted floor and the waiting time for an
available ER bed will be greatly decreased.
Boundaries to be serviced will be 2305 Square miles (5,170 km2).
"Remain Blessed"
Section 4-2
m
Care Med Transportation LLC -Collier County COPCN Application,
Section 50-55 Procedure For Obtaining a Certiflcate
Section 5
Brief overview of staffing levels hours of operation
"Runde n
Section 5
Transportation, LLC
Phone number: (239) 599 - 5606
Fax: (239) 599 - 5607
3510 Kraft Rd, Suite 200
Naples, FL 34105
Care Med BLS Transportation Possible Staffing Projection
There are 168 hours per week in total.
84 hours during the day
And
84 hours during the night.
12 hours per shift with 7 days scheduled working hours during the day with a 45-60
minutes response time
And
7 days of standby availability during the night with an hour response time.
7 day shifts per week and 7 on call shift during the night
3 shifts per EMS/RN
2 EMS/RN per shift
10 Staff Members in total.
Section 5-1
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Section 5-2
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Section 5-2
U
Care Med Transportation LLC -Collier County COPCN Application,
Section 50-55 Procedure For Obtaining a Certificate
Section 6
Name, age, address of the owner
Background, skills and experience of the applicant
(Please see attached resume)
"Ite"n Blessed"
Section 6
Care Med Transportation LLC -Collier County COPCN Application,
Section 50-55 Procedure For Obtaining a Certificate
Section 6
Name, age, address of the owner
Background, skills and experience of the applicant (Please See Attached Resume)
Nerlyne Saintyl-Agenor, was born in January 1978. She has been a Collier county resident for
over six years, and currently live at The Cove, Logan and Vanderbilt Boulevard, FL 34119; 5725
Cove Circle, Naples FL 34119.
Nerlyne Saintyl-Agenor has been in the nursing field for over 17 years providing direct nursing
care and managerial nursing care. She wanted to have her own company, one that would allow
her to use her expertise as a nurse to help those she served.
she has had indirect oversight of Non -Emergency Transportation when patients entrusted in her
care needed interfacility transfer. Realizing how much Non -Emergency Medical Transportation
is an integral part of nursing care, she created Care Med Transportation after much Prayer and
soul searching, a decision she realized would grant her the opportunity to bring her nursing hat
on the road with her as an extra tool to help patients and their loved ones when needed. Years of
expertise, and resources. Not, just transporting a patient, but also serves as a liaison officer and
advocate for the patient.
"Remain Blessed"
Section 6-1
on
Care Med Transportation LLC -Collier County COPCN Application,
Section 50-55 Procedure For Obtaining a Certificate
In 2014, she created Care Med Transportation during which endeavor she has accumulated a
great deal of experience thanks to her hands on approach with Care Med.
As a nursing professional, she has found it to be extremely important to combine her ability to
great patient care to her non -emergency medical transportation journey.
Now after five years of doing hands on Non -Emergency Ambulette Medical Transportation, and
three years since she started researching the necessary criteria by the Florida department of
health and initiated her first conversation with Collier County EMS Director Summers regarding
the BLS Licensure, she has deemed it necessary through assessment, observation and requests to
get the correct FL State licensure for Care Med in order to provide a higher level of
Non -Emergency Medical Transportation via BLS Ambulance services in order to better meet the
community needs, a service that is greatly needed in our community.
A tremendous amount of gratitude goes to the Collier County EMS, Director Summers, the many
representatives of the FL department of health, the Collier County board members, Dr. Tober, Dr.
Corpus, TSP financial group, Score of Naples and many more, who not only have guided me,
counseled me, encouraged me and mentored me in order to bring this project to life.
BLESSINGS to each and every one of you.
"Remain Blessed"
Section 6-2
Nerlyne Saintyl-Agenor, RN
CEO of Care Med Transportation LLC
L.. 3510 Kraft Rd.
Naples, FL 34105
Phone #: (239) 599-5606
E-mail: support@caremedtransportationllc.us
OBJECTIVE:
Please use as a reference of my experience in patient care and my commitment to
bringing my experience as a nurse on the road each day.
SUMMARY OF QUALIFICATIONS
Education and employment in the healthcare field. Strong commitment to promoting
wellness and preventing disease. Skill in dealing with sensitive populations in a
professional and Concerned manner. Able to work independently and as a cooperative
team member. Dedicated and willing to get the job done; always meet deadlines. Fluent
In English, Creole and French.
EDUCATION
05A6/13 -Present: Pursuing BSN online with Chamberlain College.
05/07-07/08: AS Degree- Nursing: Farmingdale State College, Farmingdale, NY.
01/05-12/05: Certificate- Practical Nursing: Farmingdale State College, Farmingdale,
NY 11735
PROFESSIONAL EXPERIENCE
Registered Nurse, 2008 -Present
Care Med Transportation LLC: March 2014 -Present, non -emergency transportation RN
Avow Hosp1ce: Seasor, a1'0 1u -4—U-1 9, uir"L Gdic tliv
Avow Hospice: December 2014 April 2016, Direct care and community RN
NCH/Brookdale Rehabilitation: January 2015 -June 2015, Rehabilitation RN
HCR-ManorCare of Naples, FL: September 2013- June 2014, Assistant Director Of
Nursing
Med Life Institute, Naples,FL: March 2013 -September 2013 clinical instructor of the
Practical Nursing program.
Lakeside Pavillion-Naples, FL: November 2012 -March 2013: Manager of the rehab
unit.
Section 6-3
Catholic Charities of Brooklyn and Queens May 2011 -February 2012: Nurse Manager
Plainview, Northshore Hospital October 2008 -September 2011: Registered Nurse Med
Surg with MRDD specialty, Remote telemetry monitoring. Geria
mentally challenged population. g trY and experience with
Excellent Home Care June 2010 -November 2010: Vsiting Nurse
Supervisor at Dalevue Nursing Home January 2009 -March 2009: Through Healthcare
Agency Services.
Licensed Practical Nurse 2006-2009
St Catherine Nursing Home, Dalevue Care Center, NY. Assist 20 residents with
medications, feeding, and examinations.
EastNeck Nursing Home/Rehabilitation Center, Babylon, NY Assist 30 residents with
medications, feeding, and examinations.
Certified Nursing Assistant April 2002 - March 2006
EastNeck Nursing Home/Rehabilitation Center, Babylon, NY.
Gurwin Jewish Geriatrics Center, Commack, NY.
Computer Skills
MS Word, Excel, PowerPoint, Point Click Care.
Reference: Available upon request.
Nerlyne Saintyl-Agenor, RN
11. _''
Section 6-4
Reference: Available upon request.
----------------------------
Nerlyne Saintyl-Agenor, RN
Section 6-5
. � wi'y�.r��•�!'Prtr :
AC# STATE OF FLORIDA
DEPARTMENT OF HEALTH
DIVISION OF MEDICAL QUAL'Ry ASSURANCE '
DATE LICENSE NO. CONTROL NO.
05102/2017 RRD34004 2430131
The REGISTERED NURSE
named below has met all requiremeriIS pt
'•`,.i� .
the laws and rules of the stave of Florida- n•_4�'—"'"-- ' ..-.-.
Expiration Date. APRIL 30, 20194,-,-
NERLYNE SAINTYL-AGENOR �; Y"„pl�. _�,
15275 COLLIER BLVD �� Y •,--� '"`•
APT# 20125E �, M tai • c'
NAPLES, FL 34199�:::'�
•t. ?fit `�'{T..._•�� •-
s
Rick Scott Celeste . hilip, h1.D., M.P.H.
GOVERNOR Surgeon General and Secretary
DISPLAY IF REQUIRED BY LAW
Ss
s_
Section 6-6
Logged In as Salnry!-Ayarrar Nedym
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Registered Nurse N 93.40654
i'�;,.".i�t��[f•it?,!'E � t!i..:{:i3:ii:'S � F'.p,lii:rs f 1,..�,IA,iAiilri
O 2019 R HsaNhSource, Ali Rights Reserved
Florida D"Orb"ant of HsaMh I Division of Medical Quality Assurance Web Portal
License Information
License Number: 9340654
License Type: Registered Mures
License Status: Clear
License Expiry: 04/30/2921
Address: 3725 Cove Cr NAPLES
FL 3411'! y
Pune: 239-449.740 fl
httpsJ/mgaonfine.doh-state.fi.us/dat3m8tVquickStadM&iuFL MOA.ft
Section 6-7
V
Care Med Transportation LLC-Colller County COPCN Application,
Section 50-55 Procedure For Obtaining a Certificate
Section 7
Quality Assurance, Quality Control & Quality Improvement Measures
Continuing Education For Staff Members
`RWWR slsssw
Section 7
'N.01
Care Med Transportation LLC -Collier County COPCN Application,
Section 50-55 Procedure For Obtaining a Certificate
MISSION STATEMENT
The ongoing process of assessing, observing and monitoring our system performance,
not only through actions. But also documentation. Care Med's Quality Assurance and
Quality Improvement is based on the belief that all measures must be taken to prevent
any and all incidents and/or accidents when possible that can deteriorate a patient's
health status. At Care Med, we believe that as a team that ONLY through continuous
education, evaluation and reevaluation, reassessment, audits, following protocols and
procedures can we achieve our goal, which is maintaining the patient safety and health
at its most acceptable medical and legal level of function.
At Care Med, each patient is seeing as a whole, we don't see diagnosis only, but strive
always to see the patient as a unique and whole individual needing our utmost best
medical skills.
• Every staff member will be vetted through proper screening and evaluation prior
to hiring.
• Staff members will go through pre-employment testing and post -offer testing.
• Ongoing unscheduled drug testing for all staff members, especially medically
skilled staff members.
- M! employees will be mandated to cor ple±A Fducafin.rj1Tra!n!ng
Programs and encourage to pursue external education/training. Some of the
internal areas of training include, but not limited to: Company policies, rules and
regulations, mission statement and goals, structure of the organisation, safe
vehicle operation and checklist prior to start of shift, expectations of staff
members level of service to the community, compliance measures, continuing
medical education, AED and CPR training, Care Med's patient assessment and
proper documentation requirements.
in-service by our Medical Director every 90 days.
"Remain Blessed"
Section 7-1
Care Med Transportation LLC -Collier County COPCN Application,
� Section 50-55 Procedure For Obtaining a Certificate
•
EMT skills
•
Infection control/Hazardous materials
•
Elder, patient and child abuse
•
Violence at work
•
Sexual harassment at work
•
Drug & alcohol related issues at work
•
Field care audit
•
OSHA
•
HIPAA
•
Scope of practice
•
Community outreach
•
Employee injury
•
Safety standards
' •
Employee performance review
•
AED protocols, documentation and required notification after each use.
Please see an example of Care Med Medical BLS Ambulance Service Checklist for
audit.
"Remain Blessed"
Section 7-2
s
P�
Trac sportatronl. L L C
Phone number. (239) 599 - 5606
Fax: (239) 599 - 5607
3510 Kraft Rd, Suite 200
Naples, FL 34105
Care Med Non -Emergency Medical BLS Ambulance Service
QUALITY CHECKLIST
This checklist is designed to be regularly completed after a specific measurement period
determined by the ambulance service, The measurement period may be monthly, quarterly,
semiannually or annually. Use the checklist to start your quality program.
Ambulance service
Measurement period dates: from to
1) CONTINUOUSLY IN SERVICE
During the measurement period, the ambulance service was continuously available for service
(did not go out of service because of staffing, vehicle, or other issues).
_ YES _ NO
2) RESPONSE RELIABILITY
During the measurement period, the ambulance service responded to all requests for service
(excluding requests that came when the ambulance service was unavailable because of being
on another call).
YES NO
3) RESPONSE TIMES
During the measurement period, the ambulance service has recorded, tracked and met state
response time requirements, including chute times (the time from first call to where rolling to the
call) and response times to the transferring facility (the time from first call to arrival to the
receiving facility.
YES NO
"Remain Blessed"
Section 7-3
u
Transportation, L L C
Phone number. (239) 599 - 5606
Fax: (239) 599 - 5607
3510 Kraft Rd, Suite 200
Naples, FL 34105
4) ON -SCENE TIMES
For the measurement period, the BLS non -emergency medical ambulance service has recorded
and reviewed all on -scenes times (the time from arrival to the transferring facility to departure to
the receiving facility) for appropriateness to the specific situation and deem them to be
appropriate
YES NO
5) 911 Emergency calls during transfer
During the measurement period, ALS intercept was initiated for all patients with chest pain or
myocardial infarction symptoms, cardiac arrests, severe respiratory distress, respiratory arrest
or severe traumatic injury.
YES N J
6) COMPLETENESS OF PATIENT CARE REPORTS
For the measurement period, all patient care reports have been reviewed by the ambulance
service Quality Coordinator for completeness, including vital signs and accurate call times.
YES NO
7) PROTOCOL COMPLIANCE
For the measurement period, all patient care reports have been reviewed by the service quality
Coordinator for appropriate care and protocol compliance.
YES NO
"Reendn Blessed"
Section 7-4
Transportation, LLC
Phone number. (239) 599 - 5606
Fax: (239) 599 - 5607
3510 Kraft Rd, Suite 200
Naples, FL 34105
8) ALL MAJOR CALLS ARE REVIEWED WITH MEDICAL DIRECTOR (MAJOR CALLS ARE
CALLS RESULTING IN 911 EMERGENCY ALS AMBULANCE SERVICE DURING
TRANSFER)
9) For the measurement period, all patient care reports that Involved cardiac arrest, traumatic
arrest, severe respiratory distress or arrest, major trauma, and/ or challenging clinical care
management during transfer have been submitted to the Medical Director for review and
feedback was received.
YES NO
10) TRAUMA, CARDIAC AND STROKE CARE AND DESTINATIONS
For the measurement period, all patient care reports that involved major trauma, possible
myocardial infarction, or possible stroke during transfer were evaluated for compliance with local
policies, protocols and destinations.
YES NO
11) CARDIAC ARRESTS
For the measurement period, all cardiac arrest during transfer 911 call for ALS ambulance
services were reviewed for appropriate stabilization care, and appropriate calling time to 911,
and transferred time to a higher level of ambulance transfer services were reviewed with the
Medical Doctor.
YES NO
"Remaln Biassed --
Section 7-5
•
Transportation, L L C
Phone number: (239) 599 -5606
Fax: (239) 599 - 5607
3510 Kraft Rd, Suite 200
Naples, FL 34105
12) During the period time all personnel Nbs were ravW&vd for up,todaft
mandatory aondnuing education and training hours.
YES -NO
13) During the period time proper dbcumen-M n vena reviewed for proper equipment
v iesdng andlor Inspecdon at the start of every shift,.
_.YES N0
M
Section 7-6
STATE OF V1,0111n.1
DEPARTMENT OF HEALTH ' EMERGENCY MEDICAL SERVICES
SERVICE RECORDS AND FACILITIES INSPECTION REPORT (SECTION 401.31, RS.)Strvicr Nanu: _ Inspection Date- f ,r
__ Phone:
County- Type of Inspection: ❑ Initial ❑ Reinspection ❑ Random ❑ Complaint ❑Announced ❑ Unannounced
•-Icenac Type: ❑ l'ranspot t ❑ Nontransport Date of Lose Inspcttio-n: I
License Eviration Dale.
inspection Cedes � — �
1 m Item meets inspection criteria. Rating Caicgories -
I a = Item corrected during inspection to meet criteria. I = Lifesaving equipment, medical supplies, drugs, records or procedures
p inspection criteria. = Intermediate support equipment, medico] supplies, drugs, records or procedures
2 =Items not in compliance with in 3 = Minimal support equipment, medical supplies, records or procedures ll
1. ADNIINISI RATIN Vf:ANDRECOltDNSTOI(AGEIChyner6lJ-1. R.A.C.]
I. Records storage and secerlly,
% RttordF Ararat:, fn S years. _ a. Ilemt an stored Ie a eiimple wnlroDed (Le. -heated and ole conditioned) location.
tl RFCDRRS (seslfoa 40i, FS Cbapirr 64J t, FAC) $ The uv es rump Aad samllary.
L Current service license on disniay. (Chnpler 64J -I, P.A.r l
641-1, F,A,C.)1
H. Verification ■ r Vehicle permil.
3 I'Mrlaen lnsprreioo Foran, (Chapter 64 J.1, F.A.C.)
4. Personnel Records for each EIIIT, paramedlc (Chapter 64J-1, F.A.C.)
T4 Include:
A. Date of ernplayascar.
IL 14 cleared of Irobviag.
C. Current professleaal etrtiaealton
D- Dueamcasonan of ramptefloo of the Ilii D.D.T. Ali illedical Cee.
Natlwal Standard Curriculum -Advanced, for Paramedic Crew members
(Chapter Ill F.A.C.
S. Aall laacu driver record (for each per Seel Ion 401211(1), F5.)
Ta ladude: Srmicn,enlr It[nfln id A.RC.
A. II years ofd.
R. NH addicted to afeol,d w ranirolled arineaaees.
C. Free from physical or mental dere- lir disease that would impair
ab{mty, to drive.
D. Driving record verinesiloa.
E. Possess valid clan `D" or chats Rear liraase.
F. Is nrahaed in safe arc—tion or emergra ty vehicle- 16 he ur E.V_().C.
R ensesao ■ valid American Red Cors First Aid and Penao l
MmSal card wits alralem,
II, Penersea ■ mild Amerinn Red Cross or Amerltan Read
Asaudsilaa CPR or ACLS card
NOTE: Careens iJlf T or paramedlc errcirxatioa 8 erld,aee of eompllann
k" A, R, C and C ahorr. (sccll.0 4e1S7(4
6, Aledical 0Lee" or (section "J-1, F.A.C.)
A, Qaaatkationr; Current ACLS eerldfiea[fan or lamed colliliaatlea in
tour enc • medicine tChs er d4 -1 FAC
d- Dulkt and rerpansibliilkI (Chapter 64]-1, F.A.C.)
I. lYdWrl lin ape nalilig proced urns for pa rdenl care.
Z. Wrlllen quality mlsonlace program operating procedures that requir
raggwia :
a. 1'rempi review of run reports.
k Dunce Ihsenatlom of parsaaacl.
wtlh
The
4. coemmemled lir parlldp.fiw In dimer eaalraes liar, wish EMS Fidd Lerd
ew'111,n for a minim lion of Ill hours per )rest,
lavestary. storage mod security procedures for melmcalloas, auids a rad eonlydkd
ut,Nanrees Stellae 4g�r 94 FS, and Chm trrs 64]-1, F.A.C.
A. t)bscrve F[ [be
1. 'log req vim cN re fur moun,1119as mod Holds are being mart:
1. Ssorage area Is fecund by a foching meehmnlsrn,
2. All (kms ore Wvntorled tit Ill a ilkly.
X Drtcriuraled or expired Ireton are stored in m quoranlinc area, ,fl from,
laid. 11 con.
,mmwnlr-
D. Dieters if l he fallowtng mquirememis far ranlr oiled loin ancrs etre bring met!
[.The req aireal is listed is brass 105 abol are blimp 111,411.
2- Medical dlrteror W rellis"d Norrye area with AEA (Chapror 64J-1, FAC.I
C. Wrllica openling procedures for the storage and handling of Holds and medlealiom Meetly 1{,r
rollnwln 1.
1.3ecwi[y procedurm
2. Item stared Ina efimxo cuntrallcd foeaiknn (i.e. - Warrd and a ireonditloned)
]. DelartanUed or ex ptred Inraa Flared Ion a gnarowimr area, sepou lc from usable Items,
t Invmalury prarcdame
D. Written operating procedures for theNorage and handling oreontrnlled suhstonces sprclfr fbr
follossin
I. Stange procedures. "-
1 The padliaas ihat have nccert >r ..trww aal,aesaou
J. ShIA ckaage Wne.iory prreedrea for reldeles.
�. Prucedurn to be reed for the doeumenlatiaaof usIt di ll I ml ofescen and reapply of
rchkks wl[h "caned sohs+eaces,_ _
S. Procedures used lar Inventory discrepapcln.
F. Verily dui the fadf wing f,emer.uh regard ie coal rolled ,uhal ancn:
I. a[or age records are motntmined on It le at the loco lion where be cooaramed sabsta
srered mees are
I An rcgrkrrd larwew•IIll fad [words an IN, 11 Ilgd at Mali two Yam
1. Retordr ase muinlalaad separRlely from ether records.
I. Eliokpn„n[ sul,stiletlons whro arlhartaelivo by medical director (Chapter 641.1, F A.C.
If' IFloeardkal 111,111 operating praerdarw (Section ]6 {.IG, F.S. and Chapters 641-1, F.A.C.) to
laeludr:
A. Paper haadling
a. Proper itaniv
C_rruprr dispaaa(
M EMS prrriders emsaeler pfaa lnteg parr[ hot} (apt and regiosat d
FACcaster plan (Chapter
.
11. Adele pod Iiediatrk CID approval r. miring by medical dlreeror (Chapter 641-1, F,A.C.)
12. Item EMS {srorlder mIII nlmkns an air masbulaacellcell it pas ill era;Td plrcna,tbr
faDowln record rI afreaseais Ibai u t Stceka lf1l.251 F.S, and Cin ter 441.1, F,A.C.
A. Eesergen" protacal for overdue alrenR,+rl,eo sadly oomn,unicaliaar ea M
_sr when mkermR nanot tee lacoted. nn ba ritahllsbed,
b. U."Un,eatatrull ON h1 n1 nNn, [vef {,� NNIl uieq f, role earmal! Ili and lraos Tleai�a laCalee•a.
C. Safely eommlttee to Ine ludc: -
1. Fleaaheno r atone pmol, oat nlghr t sh" crew wNeds r, Ill @I dhr-- E7?
[lie ■ndsat hos llmf molnhtntur I[hos Hal bra sed
2• IYclllcn aafery Praredyres. — — —
I 6LeeNa11s herd gaarserlr to review amfety pameles, p arida
ha and Iadif cn klaoeer sv11►safer olleies and raeedtrrer. uuuaual oeeurrences, aafery
■. SaFnr wadi[ reaolli con„uvairatrd It all pcte,gm persumutq,
S. Allareea .f wrrllaxs recorded Aad rctainsyl ea file for) era lir. - —
I, the undersigned representative of the above service, acknowledge receipt of a copy of this inspection narrative, applicable supplemental Inspection reports and corrective action
statement (if applicable). In addition, I am aware of the deficiencies listed (if any) and understand that failure to correct the deficiencies within the established time frames will
subject the service and Its authorized representatives to administrative action and penalties as outlined In Section 401, F.S., and Chapter 64J-1, FA.C. Copy of Inspection report
and Corrective Action Statement Received by:
,ierson in Charge: _ .. Dale:
Inspected By:
— - Date:
Section 7-7
DEPARTMENT OF HEALTH • EMERGENCY MEDICAL SERVICES
BASIC LIFE SUPPORT VEIIICLE INSPECTION REPORT (SECTION 40LjI, F,g,)
Service Name Inspection Date: / f_!
Coon 0Una
;Y: Type of IntUnt ill QlnitV r Make ectioa O Random O Cotuplaint OAaaougced ❑ Unannounced -
Vehicle lafarmadaa:O'i'rnnsportpNan-TnosportUsiNt Ygr/1Hake PrrndtType pe�(yI
VIN Too
mspenion Calcs 10I Categories-
1 =Ilan nmceu inspection rrl7ir. 1 Lifesaving equipment, medical supplies, drugs, records or procedures
Ia a Ilcm corrected during inspection to meet criteria. 2 - Intermediate support equipment, mnrmFoal s i
eappl es, dings, records re procedures
2 - Items not in compliance with inspection eriteria, ) Minimal support equipnrenl, maelilal cal sun, records s, records or
Ya,w F�fr11`AKA16RlYFR ,htTIFICATE NUP61RERIlZrmv credentials: Section 401.27(U
ICLE ItEQUIItEMENT5 (Scrri... 716 avd 401, 11 Chapter 64J -
em
E. a.ael-rep lighnsxndatd741ew7"nitsla$vier -- —
l. Ilam
4. Windshield wiper
S. riles
6. Vehicte free of cuss and 4we
7. Twas•way radio cvmnne,icelian - molls; rest
A. Hoapiul (ab ad palem cranpar..nv,al .
J. Emergency Lighu
9, Siren
10. Two AOC Grc ntir%WAwn rung ch
' Iia eaeh.
.1. Duma open properly, close seewcly.
17. Asx and f W Vices red Irons
I )- W mtknes and Windshield
And 401.281, F.S.
51blimum Q One EDIT and One Driver
1, F.A.C. and I Roll" P..c - ----
. ALP (nummum 3sa aI p,ih
. One � vrOavdcge b7aears -
. 4rx rel m7rl,v pofiem rerrramrs - wrest and ankle
t]oc corn Mood pr sure cuffs: Infant, pedinHe. and aduk.
and inspected in brulcts, Minimum
IRIII ENTS (Section 40 i, F.S., and Chapter
I . Primary fvcuber and dace w3,pL
L Atmihary stretcher and taro scraps
h. Tam eedwg nwwacd IV huidcrc --
s Two l o-JenuiIg pins
I- Oeedtead grab tail. -
6. Squad betach and Ihrer sey or seas btkL
9 Lttaahnp heiv,
10 Heal and uir cundluuniug unlit Ian.
I I. Word•"Armbularee"-aides, back and awiL
ilLMEDICAL EQUIPalF.Nr FOR TIKTINC (Chapter IM -1, P.A.C., and JCJ K.A_III
I. haaafkd auction (Installation only]
. III 7. 17, 17, IN and M in scrtion H rum he sI
IV. MEDICALSUPPLIF"9r ANDI IPFIENT(Chopler ial•I,F.A.C,CSAKKIi•A-
Ig22
1. 9audspft dresalnl and t"I mPPlitw -
i Runt allsaive, sign ar plastic rage• - - -
a iirrik Passe pwb, am
Triantul.r les ujagra — -
;na,mcnrr: ---�
I site— (ora requirW on aan-mrupun vd. irks]
i Pitkws anth waterproorcoven and pillowcases or disposable single ase pillosrc. (Not rrytrired an non
lompm vehirlca.h
k One dmspdorbk bhrmkn or ysrlrnl ram avvcr -'�--
I0. One long "Pal" baud and three strap" dr eprivcknL - —
i I. Dns flan spice hood sn! two craps or i:gstiralent
Onc sack Taduh pcdiatrim: ccrvira] ,mmehiluanion device (CID}, approved by the medical director
,rthe scnicc. This approval must be in writing and made available by the provider rar the dcptutnxnr to
svicw.
). SM ratpadding fur htcral loaner spin, immmu : iiivuiuIli of pct Is It'r patients or egrdrrsk-M
1. Two poru6le axyaea Indy, "D" cr "E" cylinders, with one regulator and gauge. Each tank must hove
rtraisaurn orlt10+0
S Pah transparent oxygan or ukr, adult, chid and in fans wme , with hsbisg
6 SO or pcdh tris and WI nasal wnulac with tabatg.
1 One each hand vgwrarcd bsg•vaiIli r mast r.sufciwtors, amkrlt and pediitill,ie accumutatmr, includini
dub, chili and M(nµ t masks a( use wid, suppl=XWAl va
S. One portable suction, electric or gas powered, with wide bore ta6Zq tips, trkieh Neel iter
siaintY
aem yaoMs as the GSA in K"_A-IILI 'I'rr>aiand
and
9 Assaned fan of ealrowity i:mnrahiliaarion dcricr>_
0. Oae tows esarnny uutsvu apltm, iPrdiatrie aid AdubY
1. One alerile absrctrini kit to include, at mininnum, bulb syringe, sterile scissorsor scalpel and card
Ian m wrd-i x
Ram sheer,
Occlusive drrmsp
AsayuY} tins of smspltarynl a:mwsys. fbdeaair and ,5akstl
One inssalled oxygen with tguialor gauge and wren..., mum "M" sire cylinder, (Other instilled
ygen delivery systems, such as liquid oxygen, as allowed by medical director. Thu approval must be .r.
itsn snd �v_allalde In the ramp for "CIA
Su(ftcirnn quantity of glnvcs - auilahle la prvvimle bgmier prvteelion Ftom bmoharaNs fes a!! sono
mmbuu.
$ufrxicm rmuanrily afro.. foral[ crnmmembeIs-Fue>tjasks surgical yaj
P c trapiratery
��. Assorted IxJianic onJ .dolt sizes rigid emical cotton u nppmved in writing by rhe medical duector
net available rat the
Nssttpharyngcal uirx•ays, intoneh IN rnn, ¢quivalcnts ( rmfant ."ohm • as! aitch
I_ floc approved tiuluwrduus wore r4rsrio bag w imprrviaus emasir,a-x per Ckapttr i4J•f. F.iC.
III Prdy[nc ten tin base! esrawrfatteat device aetecsion and den dura
0. per saewtscmbcr. cafcry goggles or eyuiaalcnt nxeting A,N 5.L7!!7. I rmaxlxd
One bulb ryringr scpamte frrxn obxletrimal kit.
Ove drartrnl al mbm relicesivc klnr2es -
.43�• Ten siwhiaanma drrsr�•y ' -- � - - -
[�IVERAI.SANfTAT10N(Sacrlan46t,26(1Ne),F,S. -
1. Vehicle and Cvarrah O Sa w-ary O Unaarl idt ry
I, the underslitned reprruntallve or the xt,ave service, arknovvkdge receipt Its copy or fids lespeclion namrlve, applicable unppkmental insprctlon reports eM corrective arrlun statement (If appn,ahkl. In ndJlttin, I
III aware of rhe defidencles Ilnetl (If any) and understand that failure to carred the deficiencies wphla the eslahlished limn, frames wilt subject the service and its authorized representatives to administrative action and
pm Iola as outlined in Section 401, F.S" and Chapter 643-1, Y.A.C. Copy or inspection sopor, and Corrective Action Statement Received b1 -
Person In Charge: _ DI
Inspected III - - -
-- Dote:
Section 7-8
Care Med Transportation LLC -Collier County COPCN Application,
Section 50-55 Procedure For Obtaining a Certificate
M
Section 8
u Ambulances' description and number of vehicles to be used
qtwnMn Bk=w
Section 8
u
t10
t
r
0
1 .urllyPortation, LLC
Phone number. (239) 599 - 5606
Fax: (239) 599 - 5607
3510 Kraft Rd, Suite 200
Naples, FL 34105
Dear Director Summers and Dear Members Of The EMA Board,
Please see model of projected ambulance Vehicles for Care Med BLS Non -Emergency
Interfacility Medical Transfers.
We will be using the Ford models with the required 'KKK 1822A" system by the
Department Of Health. The ambulances will be purchased as we get further to sending
our application to the Department Of Health.
We will be communicating frequently with Director Summers as we move forward with
this project. His expertise, wisdom and guidance would be of great value to bringing
this project to completion and continued success.
Please see attached pictures.
"Remain Blessed"
Section 8-1
T
Section 8
C'
J
J
l
14
I
-JIF - AW4
If
0
A -1
0
r
Care Med Transportation LLC -Collier County COPCN Application,
Section 50-55 Procedure For Obtaining a Certificate
Section 9
`./ Headquarters' address and other substation
`Rwmain Bkmwcr
Section 9
Care Med Transportation LLC -Collier County COPCN Application,
Section 50-55 Procedure For Obtaining a Certificate
Section 9
Headquarters' address and other substation
Headquarters' Address: 3510 Kraft Road, Suite 200
Naples, FL 34105
We currently serve the Lee county as well, doing Non -Emergency Medical
Ambulette transportation.
Address for substation in Lee County at this moment is:
8891 Brighton Lane,
Suite 129
Bonita Springs, FL 34135
"Remain Blessed"
Section 9-1
Care Med Transportation LLC -Collier County COPCN Application,
Section 50-55 Procedure For Obtaining a Certificate
Section 10
Training and experience of the applicant
"Remain Blessed"
Section 10
Care Med Transportation LLC -Collier County COPCN Application,
Section 50-55 Procedure For Obtaining a Cerdficate
Section 10
Training and experience of the applicant
m
Please See Section 6.
109
Section 10- 1
Care Med Transportation LLC-Coliler County COPCN Application,
Section 50-55 Procedure For Obtaining a Certificate
Section 11
Billing operations, office hours, provider contracts a Medical Director
Engagement
"P.wWn Blssssd"
Section 11
Care Med Transportation LLC -Collier County COPCN Application,
Section 50-55 Procedure For Obtaining a Certificate
Section 11
Billing operations, office hours, provider contracts & Medical Director
Engagement
AU billing operation will be done internally by our accounts payable department.
Office hours will be: 9AM-5PM, with an answering service 24/7.
Currently we serve many facilities within the community such as NCH, Physician's Regional,
Avow Hospice, Stand Up MRI, and we receive various calls from the community to transport
their loved ones via ambulette transport services; etc.
y • Medical Director works hand in hand with CEO & Compliance Officer to oversee all
medical function of Care Med BLS Transportation Interfacility Transfer, including all
Quality Assurance, Quality Control and Quality Improvement measures.
• CEO &/or Compliance Officer meet weekly with Medical Director
• Medical Director is always available via phone daily if needed to discuss any issues or
concerns with the Compliance officer, and weekly meeting or sooner if necessary.
• Furthermore, medical inservice/meeting with all medical staff will be conducted by the
Medical director every 3-6 months as needed.
"Remain Blessed"
Section 11
Care Med Transportation LLC -Collier County COPCN Application,
Section 50-55 Procedure For Obtaining a Certificate
Section 12
u Name and addresses of three Collier County residents acting as
references for the applicant
u
"Romain BbwsW
Section 12
Care Med Transportation LLC -Collier County COPCN Application,
Section 50-55 Procedure For Obtaining a Certificate
Section 12
Name and addresses of three Collier County residents acting as
references for the applicant
u
Mr. Henry N. Braga, M.Div.
Avow Hospice Chaplain Supervisor
(239) 261-4404
Miss. Minoude G. Jean Louis, BSN, RN
(561) 317-2926
Mr. Kelly Kinsland, LPN
(239) 777-2166
"Remain Blessed"
Section 12-1
m
m
Care Med Transportation LLC-Colller County COPCN Application,
Section 50-55 Procedure For Obtaining a Certificate
Section 13
Schedule rates
"Ramaln BNsaad"
Section 1 %r-.
:000o,obw A4
Transportation,
Phone number: (239) 599 - 5606
Fax: (239) 599 - 5607
3510 Kraft Rd, Suite 200
Naples, FL 34105
Financial Benefits
LLC
Schedule of Charges for BLS interfacility Transfer for Care
LAS ed Transoo atu,n
......�
Tyne of Service
Basic Life Support Ambulance
Additional Charges
Mileage
Provision of Oxygen (as applicable and ordered during transfer)
Standby Time (BLS Standby Each 30 minutes after the first 30 minutes
$95.00
Wait time Each 30 minutes after the first 30 minutes
Charge
$375
$6.00/mile
$50.00
$95
Section 13-1
T
Care Med Transportation LLC -Collier County COPCN Application,
Section 50-55 Procedure For Obtaining a Certificate
Section 14
Financial compilation of profit and loss for the past year, 2018
'mRwndn 018820r
Section 14
��
CARE MED TRANSPORTATION LLC
FINANCIAL STATEMENTS
I YEAR ENDED DECEMBER 31.2018
Section 14-1
CARE MED TRANSPORTATION LLC
TABLE OF CONTENTS
YEAR ENDED DECEMBER 81, 2018
U
ACCOUNTANTS' COMPILATION REPORT
FINANCIAL STATEMENTS
STATEMENT OF ASSETS, LIABILITIES, AND MEMBER'S EQUITY 2
STATEMENT OF REVENUES AND EXPENSES 4
m
Section 14.2
ACCOUNTANTS' COMPILATION REPORT
Management
CARE MED TRANSPORTATION LLC
Naples, Florida
Management is responsible for the accompanying financial statements of CARE MED
TRANSPORTATION LLC which comprise the statement of assets, liabilities, and member's equity as of
December 31, 2018, and the related statement of revenues and expenses for the year then ended in
accordance with accounting principles generally accepted in the United States of America. We have
performed a compilation engagement in accordance with Statements on Standards for Accounting and
Review Services promulgated by the Accounting and Review Services Committee of the AICPA. We
did not audit or review the financial statements nor were we required to perform any procedures to
verify the accuracy or completeness of the information provided by management. Accordingly, we do
not express an opinion, a conclusion, nor provide any form of assurance on these financial statements.
Management has elected to omit substantially all of the disclosures and the statement of cash flows
required by accounting principles generally accepted in the United States of America. If the omitted
disclosures and the statement of cash flows were included in the financial statements, they might
influence the user's conclusions about the Company's financial position, results of operations, and cash
flows. Accordingly, the financial statements are not designed for those who are not informed about such
matters.
Accounting principles generally accepted in the United States of America require that a 100% owned
subsidiary be consolidated with the parent. Management has informed us that the Company has not
performed this consolidation in the accompanying financial statements but has accounted for this
subsidiary at cost adjusted for cash infused or returned. Management has not determined the effect of
this departure on the financial statements.
Premier Tax Advising Group LLC
Naples, Florida
March 12, 2019
(3)
Section 14-3
CARE MED TRANSPORTATION LLC
STATEMENT OF ASSETS, LIABILITIES, AND MEMBER'S EQUITY
DECEMBER 31, 2018
(SEE ACCOUNTANTS' COMPILATION REPORT)
ASSETS
Current Assets
Bank Accounts
BUSINESS SAVING (3163)
WELLS FARGO 13ANK 5080
Total Bank Accounts
Accounts Receivable
Accounts Receivable (AIR)
Total Accounts Receivable
Total Current Assets
Fixed Assets
2003 E-250 Ford Van
stretcher
Vehicles
wheelchair
Total Fbwd Assets
TOTAL ASSETS
LIABILITIES AND EQUITY
Liabilities
Current Uabllldw
Credit Cards
WELLS FARGO BUSINEWSECURED CREDIT CARD (5552)
Total Credit Cards
Other Current UabBtfles
Due to Premier Tax Advising Group LLC
Total Other Current LhUnes
Total Current Uab="
Long Term Liabilities
Notes Payable
Total Long Tenn Liabilities
Total LIabildos
Equity
Owners Investment
Owners Pay & Personal Expenses
Retained Earnings
Not Income
Total Equity
TOTAL LUU31UTIES AND EQUITY
(4)
i 102.89
1,586.16
1.689.08
185.00
188.00
1,874.05
12,000.00
2,400.00
47,885.85
400.00
62,683.85
84.589.90
2,100.00
2,100.00
2,100.00
33,171.78
33,171.78
35,271.78
4,014.62
-89,939.78
43,147.01
72,088.27
29,288.12
$ 64,859.90
Section 14-4
Mw
Mw
CARE MED TRANSPORTATION LLC
STATEMENT OF ASSETS, LIABILITIES, AND MEMBER'S EQUITY
DECEMBER 31, 2018
(SEE ACCOUNTANTS, COMPILATION REPORT)
Income
Services
Total Income
Gross Profit
Expenses
Accounting Fees
Advertising 8, Marketing
Bank Charges & Fees
Car & Truck
Contractors
Fuel Expense
Insurance
Interest Paid
Job Supplies
Legal & Professional Services
Meals & Entertainment
Merchant Charges
Office Supplies S Software
Officer Salary
payroll taxes
Rent & Lease
Repalrs 8, Maintenance
Taxes & Licenses
Telephone
Travel
Uncatsgorbwd Expense
Uniform Expense
website
Total Expenses
Net Operating Income
Other Income
Interest Income
Total Other Income
Other Expenses
Postage
Total Other Expenses
Net Other Inoome
Net Income
(5)
$ 149,286.00
149.286.00
149,286.00
2,000.00
1,013.85
1,040.04
5,345.07
31,767.13
9,134.30
5,444.72
4,957.28
1,743.10
1,381.63
260.17
2,375.46
3,520.74
1,019.18
2,782.75
384.50
1,587.07
222.70
237.00
939.44
77,156.13
72,128.87
63.ED
63.60
(63.60)
i 72,066.27
Section 14-5
•
'a tion, LLC
Phone number. (239) 599 - 5606
Fax: (239) 599 - 5607
3510 Kraft Rd, Suite 200
Naples. FL 34105
We are currently working with:
Soore Of Naples
TSP Financials
Premier Tax Advising Group
And two other financial companies to meet the financial goal to bring this project to
completion.
Section 14-E
u
F,1
LJ
Assets:
No assets
4■
i
i
`ation, LLC
Phone number. (239) 599 - 5606
Fax: (239) 599 - 5607
3510 Kraft Rd, Suite 200
Naples, FL 34105
Financials For Care Med Transportation
Please see attached Financial Statements for 2018
"Remain BWs*W
Section 14-7
CARE MED TRANSPORTATION LLC
FINANCIAL STATEMENTS
YEAR ENDED DECEMBER 31, 2018
u
Section 14-8
CARE MED TRANSPORTATION LLC
TABLE OF CONTENTS
YEAR ENDED DECEMBER 31, 2018
ACCOUNTANTS' COMPILATION REPORT
FINANCIAL STATEMENTS
STATEMENT OF ASSETS, LIABILITIES, AND MEMBER'S EQUITY 2
STATEMENT OF REVENUES AND EXPENSES 4
Section 14-9
ACCOUNTANTS' COMPILATION REPORT
Management
CARE MED TRANSPORTATION LLC
Naples, Florida
Management is responsible for the accompanying financial statements of CARE MED
TRANSPORTATION LLC which comprise the statement of assets, liabilities, and member's equity as of
December 31, 2018, and the related statement of revenues and expenses for the year then ended in
accordance with accounting principles generally accepted in the United States of America. We have
performed a compilation engagement in accordance with Statements on Standards for Accounting and
Review Services promulgated by the Accounting and Review Services Committee of the AICPA. We
did not audit or review the financial statements nor were we required to perform any procedures to
verify the accuracy or completeness of the information provided by management. Accordingly, we do
not express an opinion, a conclusion, nor provide any form of assurance on these financial statements.
Management has elected to omit substantially all of the disclosures and the statement of cash flows
required by accounting principles generally accepted in the United States of America. If the omitted
disclosures and the statement of cash flows were included in the financial statements, they might
influence the user's conclusions about the Company's financial position, results of operations, and cash
flows. Accordingly, the financial statements are not designed for those who are not informed about such
matters.
Accounting principles generally accepted in the United States of America require that a 100% owned
subsidiary be consolidated with the parent. Management has informed us that the Company has not
performed this consolidation in the accompanying financial statements but has accounted for this
subsidiary at cost adjusted for cash infused or returned. Management has not determined the effect of
this departure on the financial statements.
Premier Tax Advising Group LLC
Naples, Florida
March 12, 2019
(3)
Section 14-14
CARE MED TRANSPORTATION LLC
STATEMENT OF ASSETS, LIABILITIES, AND MEMBER'S EQUITY
DECEMBER 31, 2018
(SEE ACCOUNTANTS' COMPILATION REPORT)
ASSETS
Current Assets
Bank Accounts
BUSINESS SAVING (3163)
WELLS FARGO BANK 8060
Total Bank Accounts
Accounts Receivable
Accounts Receivable (A/R)
Total Accounts Receivable
Total Current Assets
Fixed Assets
2003 E-250 Ford Van
stretcher
Vehicles
wheelchair
Total Fixed Assets
TOTAL ASSETS
LIABILITIES AND EQUITY
Liabilities
Current Liabilities
Credit Cards
WELLS FARGO BUSINESS SECURED CREDIT CARD (5552)
Total Credit Cards
Other Current Liabilities
Due to Premier Tax Advising Group LLC
Total Other Current Liabilities
Total Current Liabilities
Long -Term Liabilities
Notes Payable
Total Long -Term Liabilities
Total Liabilities
Equity
Owner's Investment
Owne►'s Pay & Personal Expenses
Retained Earnings
Net Income
Total Equity
TOTAL LIABILITIES AND EQUITY
(4 )
= 102.89
1,586.16
1,689.05
185.00
185.00
1,874.05
12,000.00
2,400.00
47,885.85
400.00
62,685.85
64,559.90
2,100.00
2,100.00
2,100.00
33,171.78
33,171.78
35,271.78
4,014.62
-89,939.78
43,147.01
72,066.27
29,288.12
S 64,559.90
Section 14-11
L�
CARE MED TRANSPORTATION LLC
STATEMENT OF ASSETS, LIABILITIES, AND MEMBER'S EQUITY
DECEMBER 31, 2018
(SEE ACCOUNTANTS' COMPILATION REPORT)
Income
i 149,248.00
Services
149,286.00
Total Income
149,248.00
Gross Profit
Expenses
2,000.00
Accounting Fees
Advertising & Marketing
1,013.85
1,040.04
Bank Chaes Charges & Fe
5,345.07
Car 3 Truck
31,767.13
Contractors
9,134.30
Fuel Expense
5,444.72
Insurance
4,957.28
Interest Paid
1,743.10
Job Supplies
Lega18 Professional Services
1,381.83
Meals & Entertainment
280.17
Merchant Charges
Office Supplies & Software
2,375.46
Officer Salary
3,520.74
Payroll taxes
1,019.18
Rent 3 Lease
2, 782.75
Repairs 8 Maintenance
384.50
Taxes & Licenses
1,587.07
Telephone
222.70
Travel
237.00
Umeategorhed Expense
939.44
Uniform Expense
wabsRe
77,158.13
Total Expenses
72,129.47
Net Operating Income
Other Income
Interest Income
Total Other Income
Expenses
Ottw
Postage
63.60
Total Other Expenses
(83.80)
Net Other Income
i 72,088.27
Net Income
--
(5)
Section 14-12
TSP f I'VANC IAL GROUP, LLC'- ADJ'ISOR)"SER17CF_ AGREE,ifENT
V Between:
CAREMED TRANSPORTATION, LLC (and its officers,
affiliates, subsidiaries, and related companies)
3510 KRAFT ROAD, SUITE 200
NAPLES, FL 34105
(Referred to as the "SPONSOR")
Agreement Date: 4/16/2019
TSP Financial Group, LLC
(and its officers, affiliates, subsidiaries, partners, and related
companies including TSP Financial Group, LLC,
13650 Fiddlesticks Blvd., 202-175, Fort Myers, FL 33912)
(Referred to as the "FINANCIER")
In Reference To:
The financing: To provide financing up to USD $150,000.00 total project financing for providing working capital and financing
for the CAREMED TRANSPORTATION AND VEHILCLE PURCHASES For Business Operations.
(Referred to as the "Project(s)")
For valuable consideration, the receipt and sufficiency of which is hereby acknowledged, the parties agree as follows:
1. Affirmation of Authority: The SPONSOR affirms it has full authority to authorize and execute financing for the
Project as described in this agreement and the person signing this agreement shall be the individual signing on behalf
of the Borrowing Entity.
2. Affirmation of Control: The SPONSOR affirms that he has full authority and control to execute this agreement and
any docs related the financing of the project.
3. Financing: The type of financing requested (referred to as "Financing") and further referenced in this agreement shall
be:
a) Project Debt Financing
4. FINANCIER is hereby engaged solely for purposes of financing the project in accordance with the terms of this
agreement and is authorized to arrange Financing for the project from its lending relationships. Any lending
`J relationship introduced by the FINANCIER will be considered "Sourced Lender" by the FINANCIER. Any transaction
which leads to the funding of the SPONSOR by a Sourced Lender will warrant a fee due as outlined in section 5.
5. Assignment: The FINANCIER has rights to source the Financing as outlined in this agreement. Any Financing
(outlined in Section 3) sourced for the Projects by the FINANCIER will warrant a fully earned fee described Section 6.
6. Financing Request: The SPONSOR is requesting an estimated financing amount and agrees to pay the respective
fees below:
Finaric Type I Financing Request I Fee for Financina i Pa t Schedule
Project Debt/Equity I $150,000.00(One 5.00% (FIVE Percent) of 100% (One Hundred perce
Financing Hundred and Fifty total GROSS proceeds of Fee due at initial closing.
Thousand) awarded.
Commitment/UW Fee:
$1,500.00(Deducted from
Closing Proceedsl
7. Indicative Terms: The SPONSOR has provided a sample term sheet. The FINANCIER neither approves or denies
any terms of the term sheet provided. The FINANCIER shall provide the indicative terms below pending due diligence
by a Sourced Lender. The terms below are estimates and final terms will be as agreed upon between the Sourced
Lender and SPONSOR before closing.
ESTIMATED TERMS, FEES, POINTS. AND CLOSING COSTS FROM FINANCIERISOURCEO LENDER
TSP F°naoc!W Grour, LLC InfoQTSPFiranica*=p.wm www.TSPFirranciatGroup.00m
Section 14-13
iii�3
FINANCIAL GROUP
TSP FI.V!-1 AT(7A1, GROUP, LLC' -- AD ['I.SOR l' SF_R G'ICC AGRL- I, IF,,,'T
Proceeds: $150,000.00 (One Hundred and Fifty Thousand Dollars)
r Interest Rate: TBD Estimated 5.50% - 18.50% (Five and a half to Eighteen and a half Percent)
Lender Points: TBD
Commitment Fee: $1,500.00(Deducted from Closing Proceeds)
Closing Cost: TBD
Term: TBD
Source: Elite Private Investor / Private Equity Fund / Investment Banking Firm / Pension Fund
8. The Fee. The fees shall be deemed earned once the FINAL Commitment Letter, issued by the FINANCIER/Sourced
Lender, has been negotiated and agreed to by the SPONSOR. The fees shall be payable at Closing by certified bank
check or wire transfer. This Agreement shall serve as SPONSOR's authorization to the FINANCIER/Sourced Lender
and their respective attorneys as notice to allow the Fees due to the FINANCIER be paid out of the proceeds from the
Financing and shall be disbursed to FINANCIER at Closing in accordance with FINANCIER's instructions.
In the event a Sourced Lender funds the entire project, inclusive of all the phases,
In the case where failure to close is due to willful default by the SPONSOR, the fee is deemed to be fully earned and
payable upon demand. This Fee clause shall survive any termination of this Agreement so long as the Fee is deemed
earned as mentioned above.
9. Definitions
a) "Closing" means an event on a dale at which the funding of the Financing actually occurs, whenever such occurs.
k10. Non -Circumvention. SPONSOR agrees not to engage with OR consummate any transactions with any Sourced
Lenders which the FINANCIER has introduced to the SPONSOR without agreed upon compensation commensurate
with that outlined in this agreement AND without the FINANCIER's prior written consent. This clause shall prevail and
remain in effect after the conclusion or expiration of this agreement for a period of 5 -years.
11. Future Financing and Executed Options. If any financing is transacted from a Sourced Lender within a period of 60
months after the closing occurs, the SPONSOR agrees to pay a fee commensurate with those outlined in Section 6 of
this agreement at the time a closing occurs. It is the SPONSOR'S duty to inform the FINANCIER of any closing 30
days prior to its scheduled date AND to pay the FINANCIER the fees at the closing. This clause and its terms shall
renew at every closing.
12. Lender Fees. The SPONSOR understands that the lender may require a deposit prior to issuance and acceptance of
a loan commitment. Any such deposits will be collected and retained by the lender, subject to the lender's policies
and procedures. Further, the fee is independent of any requirement of such a deposit, whether or not SPONSOR pays
or fails to pay such deposit.
13. Financing Terre Sheet is An Estimates. The SPONSOR understands and agrees that this Agreement is not the
FINAL closing statement and is a rough estimate (90% Accurate), and that the proposed financing may be modified
and/or changed before receiving the FINAL closing statement/documents from FINANCIER AND/OR SOURCED
LENDER.
14. Term of this Agreement. The term of this agreement shall be for 60 -days staring once all parties have executed this
agreement. Any delay incurred by the SPONSOR's actions being deemed unresponsive or subversive shall extend
the tern of this agreement by the term of the delay. Notice of delay shall be provided at the discretion of the
FINANCIER Upon the condusion of the term of this agreement. if, at any point in time, the SPONSOR is engaged
With ANDIOR continues to negotiate with any Sourced Lenders sourced by the FINANCIER. this agreement and all
the terms herein shall remain In full effect until the SPONSOR ceases to engage or negotiate with any Sourced
Lenders.
15. Entire Understanding. This agreement constitutes an entire understanding and cannot be modified unless agreed to
in writing and signed by all parties. This agreement shall be binding upon the parties hereto and their respective
successors and assigns.
21Pag*c
T5? Fina:+tial Group, I,LC • Inr 75PFinanicalGrou .earn • www.TSPFinarida1Grau .cam
Section 14-14
ia�3
FINANCIAL GROUP
7SP FJMAArCLAL GROUP, LLC— AD['ISORYSERVICf;AGRL-'F_MENT
16. Confidentiality of this Information: SPONSOR agrees to keep all information produced by the FINANCIER including
Quotes, Term Sheets, and Sourced Lenders strictly confidential. Any information shared to any party, Including but not
limited to, competitive lending sources, shall be considered a material default by the SPONSOR and shall cause the
fee to be fully earned and payable at closing.
17 Notices. Any notices sent or required to be sent pursuant to this Agreement shall be in writing and be deemed to be
duty served if mailed (physically or electronically with receipt), postage prepaid, certified mail, return receipt requested,
or delivered by Federal Express or other comparable overnight carrier, or delivered in hand by a duly appointed
constable, to the addresses of the parties stated below or to such other addresses as either party may notify the other
by notice given pursuant to this paragraph.
18. Unenforceability. In the event that any portion of this agreement shall be deemed null and void or unenforceable by
any court of competent jurisdiction, then notwithstanding the same, the remaining provisions of this agreement shall
be full force and effect.
19. Governing Law. This Agreement shall be governed, construed, and enforced in accordance with the laws of the State
of Florida, without regard to its conflict of laws rules.
20. Signatory Authority. The person(s) executing this agreement hereby represent and warrant that each respectively
has the authority to execute this agreement on behalf of the party for which he is executing.
DATED: 4/1612019
Tne FINANCIER
TSP Financial Group, LLC
Terence S. Phlltips Managing Partner
Print Title
FINANCIER -
The SPONSOR:
CAREM T P0RTATION. LLC
X
s �
Nert ne Sai I -A anor P end 7CEO
Print
-SPONSOR
Understood and Agreed,
31Page
TSP FinanclTl Group. LLC • rnhJJTSPFinMj3 1G P•cCWn www_TSPFNancalGroup.Corn
Section 14-15
Care Med Transportation LLC -Collier County COPCN Application,
Section 50-55 Procedure For Obtaining a Certificate
Section 15
Deteriorating Patient Condition enroute, or discovery of patient with
multiple injuries or illness with rapid declining stability, ER Admission
& 911 Calls
pRemnn
Section 1 %
Care Med Transportation LLC -Collier County COPCN Application,
Section 50-55 Procedure For Obtaining a Certificate
Section 15
Deteriorating Patient Condition enroute, or discovery of patient with
multiple injuries or illness with rapid declining stability, ER Admission
& 911 Calls
Deteriorating Patient Condition enroute. or discovery of patient with multilk
injuries or illness with raQid declining stability: Stabilize patient per
Care Med's BLS Medical Protocol
STABILIZE
�" PATIENT
AND
CALL 9 11
"Remain Blessed"
Section 15-1
Care Med Transportation LLC -Collier County COPCN Application,
Section 50-55 Procedure For Obtaining a Certificate
Section 15
Deteriorating Patient Condition enroute, or discovery of patient with
multiple injuries or illness with rapid declining stability, ER Admission
$ 911 Calls
ER Admission
As a Non -Emergency BLS Medical Interfacility Ambulance Services, Care Med BLS will
not transport any patient to the emergency room, regardless of patient's status,
condition or reasons for going to the emergency room.
Care Med BLS Ambulance Medical Interfacility Transfer Services will only transport
discharged patients out of the emergency room to their discharged location as ordered
by their treating/discharged physician at the time of discharge.
911 Calls
Care Med BLS Medical Interfacility Transfer will not respond to any 911 calls from the
community. All 911 Calls must be and will be rerouted to the 911 Collier County
dispatcher.
"Remain Blessed"
Section 15-2
9T
Care Med Transportation LLC -Collier County COPCN Application,
Section 50-55 Procedure For Obtaining a Certificate
Section 16
Oxygen Protocols, AED Protocols, Medications Protocols, Transfer &
BLS Protocols -Written Approval by Dr. Robert Tober and Care Med's
Medical Director (Please see signed BLS medical and medication
protocol appendix)
"Remain Blessed"
Section 1 E
N%-10.1
L�
A4
I r"11 Urn
tatlo, l '00
Phone number: (239) 599 - 5606
Fax: (239) 599 - 5607
3510 Kraft Rd, Suite 200
Naples, FL 34105
Meeting held with Dr.Tober, Collier County Chief Medical Director on Monday April 22, 2019 to
present COPCN application, review Care Med Non -Emergency Medical BLS Transfer Protocols
and make recommendations. Also present during that meeting were, Assistant Chief Bruce
Gastineau and Deputy Chief Noemi Garcia.
Dr. Tober has given his approval to continue with the COPCN application.
All protocols reviewed and discussed with Chief Medical Director, Dr. Corpus Ian.
"Remain Blessed"
Section 16-1
� Transportation,
Phone number: (239) 599 - 5606
Fax: (239) 599 - 5607
3510 Kraft Rd, Suite 200
Naples, FL 34105
Dear Dr. Tober,
LLC
On behalf of Care Med Transportation, I Thank You for your time, guidance and support.
Respectfully yours,
Nerly a mtyl-A 'or , RN.
L
"Remain Blessed"
Section 16-2
U
u
1
Transportation, LLC
Phone number: (239) 599 - 5606
Fax: (239) 599 - 5607
3510 Kraft Rd, Suite 200
Naples, FL 34105
MEDICAL PROTOCOLS
Appendix A -Appendix
Dr. Ian Manuel G. Corpus, MD: ...............................................
SIGNATURE
Medical Director Care Med BLS Non -Emergency Medical Inter -Facility Transfer
Dr. Robert B. Tober, M.D., FACEP:....................................................
SIGNATURE
Chief Collier County EMS Medical Director
"Remain Blessed"
Section 16-3
N --,OV
Transportation, LLC
Phone number: (239) 599 - 5606
Fax: (239) 599 - 5607
3510 Kraft Rd, Suite 200
Naples, FL 34105
Care Med Transportation BLS Non -Emergency Medical Inter -Facility Transfer
Medical Protocol
Appendix A Airway Management/ Respiratory Emergencies
Appendix B Adult Cardiac Emergencies
Appendix C Environmental Emergencies
Appendix D Medical Emergencies
Appendix E ObstetricalI Gynecological Emergencies
Appendix F Pediatric/ Adolescent Emergencies
Appendix G Trauma Emergencies
Appendix H Procedures
Appendix I Medications
"Remain Blessed"
Section 16-4
Appendix A
Airway Management/Respiratory Emergencies
Baseline pulse oximetry must be establish prior to leaving discharging facility while
assessing the patient's respiratory rate. It is a part of the vital signs that must be
assessed and recorded. Assessing patient's ability to breathe and maintaining basic
oxygenation is a continuous needed assessment during BLS interfacility transfer.
When it comes to Airway management continuous "ABC" assessment is a
must during interfacility transfer and considered a part of the recorded vital
signs.
Oxygen therapy can only be administered as a continuous order from the
discharging/transferring facility's treating doctor ( the oxygen order the
patient is on at time of discharge is what becomes the patient's continuous
oxygen order for transfer).
Oxygen can also be applied as an emergency life saving measure in an
emergency situation; during which 911 must be called and care of patient
transferred to the higher level of ambulance transfer (ALS).
911 MUST be called for All respiratory emergencies during BLS interfacility
transfer:
A) Basic EMT/Driver PULLS OVER, CALLS 911
B) Rescue EMT ASSESS patient ( pulse ox, respiratory
assessment, APPLIES OXYGEN, INITIATES CPR IF NECESSARY
AND APPLICABLE)
C) Rescue EMT and Basic EMT must work together as a team to keep
the patient alive.
ALL EFFORTS MUST BE MADE TO MAINTAIN LIFE IF AT ALL
POSSIBLE UNTIL RELIEF ARRIVES.
Section 16-5
Appendix B
Adult Cardiac Emergencies
We DO NOT transfer any patient having any emergency.
EMT/DRIVER PULL OVER, CALL 911, AND ASSIST RESCUE EMT WITH SAVING
PATIENT'S LIFE.
EMT/RESCUE (EMT WITH PATIENT) START CPR IF APPLICABLE.
IF PATIENT IS A DNR, PLEASE MAKE PATIENT AS COMFORTABLE AS POSSIBLE
AND PROVIDE COMPASSIONATE AND THERAPEUTIC COMFORT (HOLD THE
PATIENT'S HAND). -DE TH CAN BEA SCARY PROCESS 1= H PATTEN ET
NO ONE DIE ALONE AND WITHOUT LOVE
71:1115 MOMENT JS YO R MOST
CRUCIAL ONE AS A HEALTHCARE PROFESSIONAL
For adult cardiac emergency in the BLS ambulance during interfacility
transfer:
A) Basic EMT/Driver PULL over and Call 911 (be ready to provide all necessary
information, including location of the BLS non -emergency ambulance)
B) Rescue EMT Assess patient, start CPR
C) Rescue and Basic EMT work together until ALS transfer arrives to save the
patient's life.
D) AED may be used when necessary (a report must be filled out and CO notified
immediately after the cardiac emergency necessitating the AED usage in order
to notify the medical director and review that proper protocols were followed).
New onset of chest pain during BLS transfer is an emergency, even if
the patient is a DNR.
If patient is a hospice patient and has a DNR, CALL the hospice house
nurse Immediately and continue with transfer, UNLESS OTHERWISE
SPECIFIED BY THE HOSPICE NURSE UNDER THE DIRECTION OF
THE HOSPICE DOCTOR. (RECORD NAME OF THE NURSE IN THE
TRANSFER NOTE).
Section 16-6
i
�J
Appendix C
Environmental Emergencies
As a non -emergency BLS medical ambulance, we can not act independently
during any emergency in the community, and we will not. All efforts will be made
by the management team to collaborate with the Collier County EMS department
to unite our efforts to serve our community.
We can ONLY operate under the guidance of The Collier County EMS Department,
and we will do so in any environmental emergency if requested by the Collier
Chief EMS.
During an environmental emergency every team member must get in touch with
the office for proper guidance.
No vacation will be honored during an environmental emergency.
Section 16-7
on
Appendix D
Medical Emergencies
Any medical emergency during Care Med's BLS non -emergency medical interfacility
transfer must be handled with the utmost urgency in order to preserve life:
A) Basic EMT PULL OVER, CALL 911
B) Rescue EMT STABILIZE THE PATIENT
C) Basic EMT HELP Rescue EMT TO Stabilize the patient until ALS ambulance
help arrives.
Care Med Transportation BLS Non -Emergency Medical Inter -Facility Transfer Services
DO NOT TRANSFER ANY PATIENT DURING A MEDICAL EMERGENCY.
Section 16-E
Appendix E
Obstetrical/Gynecological Emergencies
Not
Applicable.
Care Med BLS Non -Emergency Medical Inter -Facility Transfers DO
NOT provide any type of transportation to pregnant women.
Section 16-c
Appendix F
Pediatric/Adolescent Emergencies
Not
_ Applicable.
Care Med Transportation does not transfer children
OR ANYONE UNDER 18 YEARS OF AGE.
Section 16-10
�J
Appendix G
Trauma Emergencies
Care Med does not transfer any patient with a traumatic injury.
If a trauma emergency arises during Care Med BLS Inter -Facility Transfer:
A) Stabilize the patient and Call 911.
BOTH EMTs MUST WORK TOGETHER
AND SIMULTANEOUSLY TO SAVE THE
PATIENT'S LIFE.
Unless we are working with the Collier County EMS during
a community emergency, we do not transfer any patient
during an emergency.
Section 16-11
`.
on
Appendix H
Procedures
Not
Applicable.
No procedures can be performed in any Care Med BLS Non -Emergency
Medical Ambulance during interfacility transfer or otherwise.
Section 16-12
Appendix I
Medications
The only medication in any Care Med BLS Non -Emergency Medical Ambulance is
OXYGEN
or
02
Oxygen can only be administered as one of two ways for patients with chronic or acute
hypoxia.
1) As a continuous oxygen therapy order from the discharging/transferring doctor.
`.% 2) As a life saving measure during an emergency.
Use with CAUTION IN COPD PATIENTS and STROKE PATIENTS.
USE AS ORDERED WITHIN PROTOCOL GUIDELINES
Section 16-13
OM
0
ru.tTurtation, LLC
Phone number. (239) 599 - 5606
Fax: (239) 599 - 5607
3510 Kraft Rd, Suite 200
Naples, FL 34105
Care Med Non -Emergency Medical BLS Ambulance Services AED
Protocols
Summary of Protocols:
• Physician approved
• Will only be used by medical professionals as per the Department of Health regulation
(All persons who use an automated external defibrillator are encouraged to obtain
appropriate training, to include completion of a course in cardiopulmonary resuscitation
or successful completion of a basic first aid course that includes cardiopulmonary
resuscitation training, and demonstrated proficiency in the use of an automated external
defibrillator).
• Any person or entity in possession of an automated external defibrillator is encouraged
to notify register with the local emergency medical services medical director of the
existence and location of the automated external defibrillator.
• Will properly maintain and test the AED on a regularly scheduled basis, prior to each
shift.
• Each time the automated external defibrillator is activated, a 911 call will be placed
during the emergent medical event requesting a higher level of ambulance service in
order to get the patient the necessary life savings need as soon as possible.
• A review of the use of the automated external defibrillator will be reviewed with the
Medical Director during the soonest QA & QI review meeting.
`Remain Blessed"
Section 16-14
V
Transportation, LLC
Phone number: (239) 599 - 5606
Fax: (239) 599 - 5607
3510 Kraft Rd, Suite 200
Naples, FL 34105
"Remain Blessed"
Care Med Transportation BLS Services Full Code Protocols during
Inter -Facility Transfer
Background
Any individual in need of medical attention or requesting medical assistance of any kind
being transported via Care Med Transportation is considered a patient and can only fall
within 1 or 2 of these categories as per discharging/transferring facility:
1) DNR
2) Full Code
During Inter -Facility Transfer any patient without a Florida Yellow DNRO Form is
automatically a full code. If an emergency arises during transfer all efforts will be made
to sustain the patient's life according to Care Med's Medical Trauma Protocols until an
ALS ambulance service transport arrives.
'Remain Blessed'
Section 16-15
on
0 _r
io T
COF
�Iw� 41
Transportation, LLC
Phone number: (239) 599 - 5606
Fax: (239) 599 - 5607
3510 Kraft Rd, Suite 200
Naples, FL 34105
Care Med Transportation Protocol For Continuation Of Oxygen
Therapy During BLS Transfer
According to the FDA, Oxygen is a medication and is prescribed by a doctor. Like any other
medication, oxygen must be used carefully. As with most medications, it is ordered by a doctor
to meet a patient's specific respiratory needs.
Oxygen therapy can be ordered to be administered via: Mask, Nasal cannula, non-rebreather
mask, etc... specific to each patient's needs.
DOH requires a health care professional to monitor any patient with oxygen therapy during
interfacility transfer.
All patient transported by Care Med Transportation BLS ambulance service will continue the
same oxygen therapy during transfer as previously ordered by their treating/transferring MD; a
copy of that order will be needed during transfer and ordered by Care Med `s medical director
for continuation of medical care.
Section 16-16
.■
i
� Transportation, LLC
Phone number: (239) 599 - 5606
Fax: (239) 599 - 5607
3510 Kraft Rd, Suite 200
Naples, FL 34105
Example of Oxygen order form for continuation of care during Care Med
Transportation BLS services
Copy of treating/discharging MD oxygen therapy during treatment for continuation of oxygen
therapy during transfer: ,EMS Initial
Oxygen at LPM Via: Nasal cannula
Mask
Non-rebreather
Trach
Diagnosis for continuation of oxygen therapy per treating/transferring MD:
EMS # and signature:
Section 16-1 r
r
MD Signature
Phone number: (239) 599 - 5606
Fax: (239) 599 - 5607
3510 Kraft Rd, Suite 200
Naples, FL 34105
EMS/RN Signature
Y Trauma Protocol For Care Med Transportation During BLS Interfacility Transfer
abilize and Call 971!
What is Care Med Transportation BLS (Basic Life Service) Service?
Care Med Transportation Basic Life-support ambulance: Ambulances that are equipped with
appropriate staff and monitoring devices to transport patients with non -life-threatening
conditions as these ambulances can only provide basic life-support and non-invasive services.
Section 16-18
u
Transportation, LLC
Phone number: (239) 599 - 5606
Fax: (239) 599 - 5607
3510 Kraft Rd, Suite 200
Naples, FL 34105
Care Med Transportation BLS Ambulance Services
Protocol
What is the difference between a BLS and ALS emergency transport?
Basic Life Support (BLS) is an emergency transport provided by certified Emergency Medical
Technicians (EMTs), can also provide non -emergent interfacility transport by certified EMTs.
Advanced Life Support (ALS) is provided when a patient is in more critical condition and a
paramedic is required to assist in the treatment of the patient before and/or during transport to
the emergency facility.
Care Med Transportation Basic Life Support (BLS) ambulances will only provide non -emergent
interfacility -transfer and will be fully equipped and staffed by two highly trained Emergency
Medical Technicians (EMT"s). Care Med Transportation will provide ambulance service 7 -days a
week, 24 -hours per day throughout Collier county. All BLS ambulances will be licensed and
inspected by the Florida State EMS agency. We will use only the required ambulances by The
Florida Department Of Health with the "KKK -A-1822" (Please refer to the next page as a
reference to the Florida Department Of Health -Emergency Medical Services Basic Life Support
Vehicle Inspection Report).
Section 16-19
"rsor�rtation, LLQ
Phone number: (239) 599 - 5606
Fax: (239) 599 - 5607
3510 Kraft Rd, Suite 200
Naples, FL 34105
As a BLS ambulance:
We will only transport patients who are stable medically and who need interfacility transfer.
We will not transfer residential patients to the ER, except hospice patients as ordered by their
doctor. Hospice patients fall under the non -emergent category of patients and have their own
medical guidelines set by medicare and the department of health.
We will not transfer pediatrics patients.
We will not transfer critical care patients, which require at a minimum an ALS ambulance with a
registered nurse in the ambulance. We will not be ALS (Advanced Life Support) certified.
We will not transfer acute cardiac patients in distress, which require an ALS ambulance with a
paramedic in the ambulance. We will not be ALS certified.
We will not transfer patients with any infusion. Such as blood, or IV. We will not be certified to
do so.
we will not have any narcotics in our ambulances, that will be against the DEA law.
We are applying for the BLS (basic life support) ambulance license per Florida department of
health protocol, and will ONLY have on board our ambulances the basic necessary
requirements for the safe inter -facility transfer of stable patients.
DEA
The Drug Enforcement Administration is a United States federal law enforcement agency under
the United States Department of Justice, tasked with combating drug smuggling and
distribution within the United States. Wikimdi
Section 16-2C
u
Care Med Transportation LLC -Collier County COPCN Application,
Section 50-55 Procedure For Obtaining a Certificate
Section 17
Certificate Of Insurance, Certificate Of Workers' Compensation
Insurance, Sunbiz Registration Of Corporations & Collier County
Business Tax Receipt
ORMMn sbssw
lection 17
A�Ro� CERTIFICATE
THIS CERTIFICATE IS ksSUED AS A MATTER pF yR�LiABiLITY INSURANCE
avers IFra►mDrrrrrl
CERTIFICATE DOES NOT AFFIRIItgTfVELY OR NEGATIVELY QNLY AHD CQNFE 02!7912019
BELOW. THIS CERTIFICATE OF INSLIFtANCE DOES NOT CQHSTITUTE A END DR ALTER mE CGV£
REPRESENTATIVE OR PROt]UCE � THE CERTIfiCATE liOLOER THIS
R AHD THE C CONTRACT RETwE£N RAGE AFFORDED BY THE pOLICIEB
IMPORTANT; Ir the cerdfICate holder [t: an AOD1� lCAtE HOLDElR. THE ISSUING INSURER(S).
terms end TTONAL INttlor„ ALITFIORItFIj
FandiH¢na of the Ira11cy, certain `"'•'ho POUoy(fes) must be endorsed. Ir SUBROGA
cerllficaly hoiderI Heel Orsuch er.,fo P°IINos may require an endorsement. A sta TION IS WAIVED
F~ rsement(s). tenront on this aortlRcete r subject to the
PRODUCER Rich Mathews State Farm does not cont°r right. to the
8510 Corkscrew Palms Cir, ►t4 Rlrh me
5tatafarm Estero, FL 33928
mss kalhelino_b�ar>�
INSURED�a<F�pRpwO eGYERA l
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3510 Kraft Rd. �E R s - 14° fir' e
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THIS IS TO CERTIFY –�•, .a.1 C tw BER. -- - -
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LOCATIONS 1 VEHICLES (Ae�l ACORO I01, Adtlltlaul RMyly� behedul�, a -
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Collier County Emergency Medical Transportation
Services
8075 Lely Cultural Parkway Suite 267
Naples, FL 34113
ACORD 25 (2010105)
CANC E LLATT
slrouLD ANY OF THE~�
E T DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DA
ACCORDANCE WITH TE THEREOF, NOTICE WILL
THE POLICY PROVISIONS. BE gELtVEREO IN
X71988.2010 ACORD C
The ACORD name and logo are regfsleredmark3 of ORP❑
ACORI? RATION. All fights reserved.
1001486132849,8 Of )?-gnia
Section 17-14
S Mmit
...the people who know workers' comp'
�%.i
Member of Great American Insurance Group
February 19, 2019 Agency Fax#: 1-850-650-9288
Cissy Cooner
Acentria Insurance
4634 GULFSTARR DR
DESTIN, FL 32541
Subject: Care Med Transportation LLC
Submission number. 63269 00 lb
Price quoted is partially based on the loss information received at
the time this account is quoted. Price is subject to change based on
updated loss information.
Your submission has been approved in the following program:
o BusinessFirst Insurance Company
Your account is eligible for the following plan(s):
o Guaranteed Cost
o A Florida Safety Reward Illustration has been included if the account
meets eligibility requirements.
,,,our account has been approved in the following pay plan(s):
o Electronic Transfer - $160.00 down, and the balance in 11
equal installment(s).
The enclosed Electronic Transfer application must be submitted for
this payment plan option.
o Installment - $901.61 down, and the balance in 9 equal
insta ment(s).
o Web CAP - $160.00 down payment.
Participation in this program requires website reporting and
last two quarters of quarterly payroll documentation as reported to
taxing authorities.
In order for us to write this account, you must submit the following
required documentation:
o ACORD 130 FL, signed and notarized - must include total number of
employees by class code. The latest version of your completed
ACORD application is available on the WriteNow website.
o Mail check(s) & application(s) to: P.O. Box 3643
Lakeland, FL 33802-3643
o Hard copy loss runs if prior coverage exists
Section 17-1
Special Disclosure Notices:
o Please note continuance of coverage is contingent upon a favorable
inspection to be completed by our Loss Control Department.
o Due to the enactment of the Terrorism Risk Insurance Act of 2002,
the enclosed disclosure must be presented along with the quotation
for the states of Florida, Louisiana, and North Carolina.
o Please note that a premium credit of 5% is available to those
employers with an approved(*) drug free workplace program. For more
information on how to implement and obtain approval for a drug free
workplace program in order to receive the 5$ credit please call
1-800-282-7648 and ask for our Loss Control Department
(*Approval based on qualifications listed in F.S. 4,10.102)
Sincerely,
Laura Brennan
Underwriter
P.O. Box 988
Lakeland, FL 33802-0988
Phone: 1-800-282-7648
Fax: 1-800-611-2667
This quote will be kept on file for 60 days from the proposed
effective date.
Section 17-2
Nsilm in it'
•-the people Who know workers' cotnp'
Member of Great Arnvrcv Insurance Group
Effective Date Agreement
For coverage through BusinessFirst Insurance Company.
Agency: Acentria Insurance
Regarding Submission #: 63269 00 lb
For Submission: Care Med Transportation LLC
Please hold the effective date of 03/15/19
I agree to send all required applications, documentation, and down
payment, as indicated on my approval letter.
I understand if these items are not received by 03/19
the postmark date will be used to determine the effective date.
I understand the stated requirements for effecting coverage. I
trther understand that this form does not bind coverage nor does
� authorize binding authority to an agent or agency.
Please sign and return to the fax number listed below on or before
the effective date.
(CSR or Producer signature)
Should you need to change your effective
underwriter. date please contact your
Fax To:
Underwriter: Laura Brennan
Fax: 1-800-611-2667
P.O. Box 988
u Lakeland, FL 33802-0988
Phone: 1-800-282-7648
Section 17-3
WORKERS' COMPENSATION QUOTATION
CARRIER: BusinessFirst Insurance Company
P.O. Box 988 1-800-282-7648
Lakeland FL 33802 -
AGENCY: Acentria Insurance - 7836
4634 GULFSTARR DR
DESTIN, FL 32541
Phone Number: (850) 668-6162
Client: Care Med Transportation LLC
DBA:
3510 Kraft Road Suite 200
Naples FL 34105
Plan: 010 GUARANTEED COST
WORK RATING PERIOD: 3/15/19 to 3/15/20
CODE CLASSIFICATION
FL -Florida
7380 DRIVERS, CHAUFFEURS, MESSENGERS & HELPERS NOC
8810 CLERICAL OFFICE EMPLOYEES NOC
Total Manual Premium
Increased Employer Liability 500,000/500,000/500,000
IEL Minimum
Experience Mod
S dard Premium
Ehw.4nse Constant
Terrorism
Policy Grand Total
PAGE 1 of 1
Submission Number: 0521 063269 0000
Quote Period: 3/15/19 to 3/15/20
12:01 AM
Anniversary Rating Date: 3/15/19
PAYROLL RATE PREMIUM
82,000.00 5.87
4.813.40
25,000.00
.18 45.00
4,858.40
53.44
21.56
4,933.40
1.0_0
4,933.40
160.00
10.70
5,104.10
Minimum Premium $ 747.00
THIS IS A QUOTATION ONLY AND IS NOT A BINDER OF INSURANCE OR GU
COVERAGE REMAINS CONTINGENT UPON INSPECTION AND UNDERWRITING REVVIEW. ALL QUOTES AND
ARE SUBJECT TO OFAC CLEARANCE. PLEASE VISIT OUR WEB SITE AT WWW.SUMMITHOLDINGSTEE OF �ILITY.
INFORMATION ON OFAC REQUIREMENTS. COVERAGE
OM FOR MORE
q)M/ Date Prepared: 2/19/19 Time Prepared: 14:44:34
Section 17-4
ELECTRONIC FUNDS TRANSFER (EFT)
Summit's electronic fitnds transfer (EFT) payment option Will simplify- your payment practicessignificantl.
will automatically withdraw the correct workers' compensation premium payment from your batik account ySummit
each
month, so you never have to worry about remembering to pay your invoice on time!
How EFT helps you
• Saves time.
You make no down payment except the expense constant.*
You're in control
• You alttays know when your premium withdrawal will be made. It will be withdrawn on tllc effective day of
yourpolicy each montlt. (For example, if your policy was effective March 8, the witlidrawal would occur on the
3a, of each month.)
• You'll be reminded of your EFT in your monthly, invoice.
• Any fluctuation in the amolmt of withdrawal Will be reported to you in advance of tlhc transfer on your invoice.
• You can end your parlicipation in the EFT program at any time Willi a minimum 10 -day notice.
Note: 1"ou can also have claints c•haiges and audit p«t�nre:rttc been -Y rvd electroniculit! Sirnplt1 cluck the «pl)ruprictte
box below.
Signing lap is easy!
✓ Simply fill out and sigh the Authorization Agreement below.
✓ Attach bank account documentation (e.g., avoided check).
✓ Mail the agreement and regtdred bank documentation to Summit Underwriting at the
address below.
*
Mote Ara! theinitial �tpense conslant chrnYe is required ar inception of the lx�licy in the %vrnr of a check tlrar must be
`r ntailedto the additss pro>:ided below: EFTdrer}is will begin lvilh the first policy installment ands will
through,f mute renewal,; den ing participation in the prngrcrm. cotrtlnrre
(LIM
cuple W11 el kuau nbrkerscomp'
Member of Great American Insurance Group
— — — — — --- — — Ctfl' HERE R MALI.
+ i �
We hereby authorize our worker,' compelLwdiou carrier to initiate We also authorize trtnsfcr of funds ror claims payments. ❑
the electronic transfer orfundv from the bank account referenced
on the altackd documentation (e.g_, voided check). We.. also �4a:dro authorize transfer of fiutdv ror audit ixtin ❑
autixnrize the frnancinI institution to process such transactions to Company nanie
our account.
Policy or submission u��i::i�r
Nve underslund that tine withdrawal will tie made on fIle eticetive — — —
ire of our policy e"ch mouth ut an "111011111 txlual to our regular
I billing for workers' compensation covemge. we S4 n�turc of o�ctncrtollicer
unden:talul that ne will Ile natitied wizen otsr ratoW has been PrintPrint aurae - —�
processed and whets the transfers begin.
We ac6rowlcdec !hal this nerectrlatl will reninin in etTect until rile " —
U:rte
we 11-Ytuinslc this coutmel, and we agree to uutify Sumntil nod Ilse Seal this furna alung mitis bank account rlucaarentariuu fu:
..._ rimuicial institution no rc%ver titwt 10 days prior to the dale n%u %%ish Summit Undcrwritine
to discontinue participation in the program. 1'0 Box 32034
Lnkeland. FL 33802-3034
DOW tnvoI.,; s►ave;
Section 17-5
Online Safety
Training Videos
Workplace safety is important for every business, and so is educating your employees about safe work practices.
To help, Summit offers you access to a wide range of online safety training videos and supplemental resources.
Safety education at your fingertips!
A safe workplace is one of the hest and smartest—things you can provide for your employees. A strong,
well-rounded safety program can help you reduce injuries, improve productivity and morale, reduce downtime—and
Potentially lower your mod. This convenient and easy-to-use tool can be an integral part of any safety program,
including new -employee training and refresher classes for all staf.
• 24/7 access
• Videos cover many industries, hazards and general
safety topics
• Mobile ftiendly
• Closed captioning and full -screen mode options
• Training delivered anytime, anywhere!
• Many videos available in Spanish
• Supplemental materials, such as quizzes and
training guides, available for many videos
Get started
• More than 500 videos in 60 -plus categories:
+ Safety awareness and leadership
+ Transportation safety
+ Ergonomics
+ Construction safety
+ Heat stress
+ Hospitality and restaurant safety
+ Fall protection
+ Retail safety
+ Electrical safety
+ School -site safety
+ And many more!
To request access to this online safety resource, please email SajetyResow-ceRequest@summitlioldings.com, or visit
our website at wwwsummitholdings.com and click on Online Safety 11raining Videos in the Safety Resources
section. If you have any questions or technical issues, please email SafetyResou►oeRequest@su►nmiiholdings.com.
[!videos provided through Long Island Productions, Inc., dba Training Network NOR; a Summit vendor)
(;S m it'
. the people who know workers' comp'
Member of Great American Insurance Group
wt1'ltt summitholdings. com
SUMMIT LOSS PREVENTION SERVICES
CORPORATE OFFICE F7oilda
PO Box 988 • Lnkeland, FL 33802-0988 •863-665.6060. 1-900-282-7648- Fax 863.665-3546
SOUTHEAST REGION Georgia, Indiana. Kentucky, North Carolina, South Carolina. Tonnessee
PO Box 600 . Gainesville, OA 30503-0600.678.450-5825. 1-800.971-2667 • Fax 863-665-3546
SOUTHWEST REGION Alabama, Arkansas, Louisiana, Mississippi. Texas
PO Box 80439 • Baton Rouge, LA 70898-0439.225-926-3264.1-800.421-2944 • Fax 225-9264026
The information presented in this publication is Intended to provide guidanceand Is not Intended as a legal Interpretation of any federal, state or local haws, rules or regulations
applicable to your buslnem"rhe loss prevention Information provided is Intended only to assist pokyholders of Summit managed Insurers in the managementor potenttal lo
producing conditions involving their premises ancilbroperations based an generally accepted safe practices. in providing such information, Summit Consulting LLC does not
warrantthat all potential hazards orconditions have been evaluated orcen be controlled. Itis rot Intended as an offer to write Insurance forsuch conditions or exposures.The
liability of Summit Consulting LLC and its managed Insurers is IkWted to the terms, limits and conditions of the Insurance policies underwritten by any of them.
9LCS070710117 i17-1560102017 Summit Consulfina LLC. 2310 Coro,— pain Drive. Lakeland. FL 39801
Section 17-6
LOS URE NQTiCE Of= TERRORISM INSURANCE COVERAGE
THE TE SM RIS INSURANCE ACT
Coverage for acts of terrorism is IrrGluded In your policy. You are hereby notified that under the Terrorism
Risk insurance Act, as amended in 2015, the definition of act of terrorism has changed. As defined in
Section 102(1) of the Acte The term "act of terrorism" means any act or acts that are certified by the
Secretary of the Treasury --in consultation with: the Secretary of Homeland Security, and the Attorney
General of the United States --to be an act of terrorism; to be a violent act or an act that is dangerous to
human life, property, or infrastructure; to have resulted In damage within the United States, or outside the
have been committed by an individual or individuals as part of an effort to coerce the civilian population of
United States In the case of certain air carriers or vessels or the premises of a United States mission; and to
the United States or to influence the policy or affect the conduct of the United States Government by
coercion. Under your coverage, any losses resulting from certified acts of terrorism may be partially
reimbursed by the united States Government under a formula established by the Terrorism Risk Insurance
Act, as amended. However, your policy may contain other exclusions which might affect your coverage,
such as an exclusion for nuclear events. tinder the formula, the United States Government generally
reimburses 85% through 2015; 84% beginning on January 1, 2016; 63% beginning on January 1,
2017; 82% beginning on January 1, 2018; 81% beginning on January 1, 2018 and 80% beginning on
January 1, 2020, of covered terrorism losses exceeding the statutorily established deductible paid by the
insurance company providing the coverage. The Terrorism Risk Insurance Act, as amended, contains a
$100 billion cap that limits U.S. Government reimbursement as well as insurers' liability for losses re suiting
from certified acts of terrorism when the amount of such losses exceeds $100 billion in any one calendar
Year, if the aggregate insured losses for all insurers exceed $100 billion, your coverage may be reduced.
Your policyttnsuring agreement does not contain an exclusion for losses resulting from
terrorism." Coverage for such losses is still subject to, "certified acts of
and may be limited by, all other tering, conditions and
exclusions in your Policy/insuring agreement.
THE PREMIUM CHARGE(S) FOR THIS COVERAGE FOR THE POLICY PERIOD APPEARS ON THE
ATTACHED QUOTE, NEXT TO THE SEPARATE LINE ITEM CHARGE(S) FOR 'TERRORISM". AND
WHERE APPLICABLE, "CATASTROPHE CHARGE" AND DOES NOT INCLUDE ANY CHARGES FOR
THE PORTION OF LOSSES COVERED BY THE UNITED STATES GOVERNMENT UNDER THE ACT.
Y.
01111"'WILUT'T MZ, W1,11 "m -
The summary of the Act and the coverage under your policy contained in this notice is necessarily general
in nature. Your policy contains specific terms, definitions, exclusions and conditions. in case of any conflict,
your policy language will control the resolution of ail coverage questions. Please read your policy.
If you have any questions regarding this notice please contact your sales representative or agent.
ST -ML -506 (1/15)
Section 17-7
Summit's online Monthly Payroll Reporting and Payment Program
About WebCAP
WebCAP is Summit's payroll reporting and payment
program that lets you pay your premium more accurately
throughout the year. By completing an online report each
month, you calculate your premium payment based on
your actual payroll—not an estimate.
How it works
Each month, visit WebCAP on Summit's website and enter
your payroll, including any uninsured subcontractors and
casual labor. WebCAP will calculate your premium due_
Then, simply hit the Submit button to electronically submit
your WebCAP data to our system and begin the payment
process. To avoid cancellation of your policy, electronic
submission of WebCAP reports and payments are both
due in our office on or before the 15"' of each month.
What you need to know
• One person from your company should be designated
to complete all WebCAP reports. This person must
have Internet access and a secure, Individual email
address.
(To protect the privacy of your employees, please
keep your WebCAP report confidential.)
• Electronic submission of WebCAP reports and
payments are due by the 151" of each month,
following the month being reported. (For example,
July's premium is due by August 15.)
• For any month that you do not have any reportable
payroll, a WebCAP report showing zero in the Gross
Amount column must be submitted.
• You will also receive an invoice for the expense
constant, any previous balances due, and/or any
claims on your monthly invoice date, If appropriate.
Frequently Asked Questions
How do 1 get to WebCAP?
Log Into our website, www.summitholdings.com and click
on your current policy from the landing page. Then, in
the drop-down Policy menu, click on Manage WebCAP
Reports.
For authorized contacts who need a login, visit our Online
Business Center and click on Request a Login. Complete
and submit the form, and we will email your log -in
information within two business days.
How do I input my policy number?
It is Important to include all leading zeros and dashes
when you enter your policy number. For example,
0123-00001.
Does my policy need to reflect a current annual
payroll if I am paying my premium based on
actual payroll each month?
Yes. It is critical that your current policy reflect an
accurate estimated annual payroll, because of the
various pricing factors that may affect your premium.
For example, a discount may apply to the estimated
annual premium based on the estimated annual payroll on
file—not on the payroll you are reporting monthly. If your
estimated annual payroll changes during the policy period,
It is critical that you contact your agent to have it revised.
What payroll should be included in the Gross
Amount column?
• Gross wages or salaries
• Overtime (time and a half or double time)
• Commissions
• Bonuses
• Holiday, vacation or sick pay
• Piecework, profit sharing or incentive plans
• Allowances for tools and/or housing
• Payments for employee -authorized salary
reductions, such as employee savings plans or
retirement and cafeteria plans (IRC 125).
• Uninsured subcontractor and 1099 payments (Please
see How do I report uninsured subcontractors?
on the following page.)
Note: Tips and gratuities should not be included.
How do I report uninsured subcontractors?
Include payments made to any uninsured subcontractors
by clicking the drop-down in the Uninsured Subs column
for the appropriate class code. An additional row for
Uninsured Subs will appear for you to fill in. Also, be sure
to keep copies of all insured subcontractors' certificates of
Insurance for audit purposes.
If you have questions about WebCAP or the reporting process,
call Summit's Customer Service department at 1-800-282-7648.
(Continuer)
Section 17-8
How do I report overtime?
Include the amount of overtime (Gme and half or double
time) paid In the Gross Amount column. In addition,
include overtime paid in the appropriate column (Time
and a Half or Double lime). if you have entered overtime
correctly In the Grass Amount column and the appropriate
overtime column, your gross payroll will be automatically
adjusted when the premium is calculated,
How do I add a class code?
Please contact your insurance agent to add or
change class codes. All class code changes must be
approved by Summit before that payroll can be reported
via WebCAP.
Do I submit a WebCAP report for a rnonth that i
da not have payroll?
Yes. You must complete and submit a payroll report for
each month of your policy period. Simply enter zero in the
Gross Amount column.
Flow do I report my payroll if my policy renewal
date is in the middle of a month?
Because one policy will end, and another will begin
mid -month, you must complete two reports ---one for the
first segment of the month and one for the second. For
example, if your policy renewal date is June 10, 2016, you
should complete one report for June 1 through June 9, in
the 20'17-21718 policy period. Then, complete a separate
report for June 10 through June 30, in the 2018-2019
Policy period. For your convenience, split months will be
identified on your CAP summary page.
How do I report my payroll for a multi -state
policy?
Complete a monthly report for each unit. (Units can refer
to multiple locations or entities and will show up on your
policy as 100, 101, 102, etc.)
How do I report 10cationsfentities for which
Payroll Is reported separately?
Complete a monthly report for each unit (Units can refer
to multiple locations or entities and will show up on your
poticy as 100, 101, 142, etc.)
If I discover a Mistake, can I amend a WebCAP
report that has already been submitted?
Yes. You can amend a report up until the year is audited.
Click on the Amend button next to the submitted report.
..Ihe peapte who kri0w workers'contp'
Member al Great Amedran InsuranfeGrnup
wluw.summitholdings. corn
-DOC"Wool REV 3110 02010 SUnmlt CWk2A g LLC
The data originally entered will display and can be
amended.
Will I still have a year-end audit if I use WebCAP?
Yes. While WebCAP enables you to pay your premium
more accurately throughout the year, it Is not a substitute
for a standard, year-end audit. All accounts, including
WebCAP accounts, will be audited to determine the final
premium for the policy period.
Can I pay my premium online?
Yes. You can pay your premium online with summit's
online payment service, a free service powered by
Bank of America. After submitting your payroll report, click
the Make a WebCAP Paym ent button and follow the
prompts (a one-time setup process is necessary with a
valid bank account number), Credit card payments are not
availa bie.
Where do i send my payment?
If you have chosen not to pay online. Summit will mail an
Invoice to you the next business day following submission
of a report. When you receive this invoice (usually within
5 to 7 business days), please mail your payment and
remMance stub in time to be received in our office on or
before the 15°' of the month.
Checks should be made payable to the carrier listed on
your invoice. Return the remittance stub of your invoice
along with payment to:
PO Box 32034
Lakeland, FL 33802-2034
Note: It is important to return the remittance stub from
yourinvoice along with your payment to avoid processing
delays. Please report your payroll and send your payment
in enough time to be received by our office on or before
the I& of the month.
If you believe that your payment will be late, please call
our Customer Service department at 1-800-282-7648 for
further instructions.
Cancellation
If you or your payroll processing company fail to submit
the WebCAP report and premium payment so that it
is received by the 151 of the Tlonth, Summit will begin
the Process of cancelling your policy's coverage. If this
happens, you may forfeit any Safety Reward for which you
may have qualified.
SUMMIT UNDERWRITING DEPARTMENT
CORPORATE OFFICE Fiarida
PO Box 3643 - Lakeland, FL 33802-3643.863-665-6060. 1-800-282-7648 - Fax 1-800-611-2667
SOUTHEAST REGION Ceargin, Indiana, genrrru4y, Norilt Carolina, South Carolina, Ten+ressre
I'o Box 600 - Gainesville, GA 30503.0600.676-450-5825. 1-800-971-2667 - Fax 1-877-288-9774
SOUTHWEST REGION Arabans, Arkansas, Loulsiona, M4seLsslppl, Teens
PO Box 80439 - Batou Rouge, LA 70898-0439.225-926-3264. 1-900-421-2944 - FaX 1-866-256-8389
Section 17-9
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CARE MED TRANEPORTATION, L.L.C.
- 1WumwK
FaMNwnbw
L140 M1797
Dub Filed
0391/2014
Slab
Sb"
FL
Last lvwd
ACTIVE
LC AMENOMOff
E"M Dab Filed
042U2014
Event N afts Dab NONE
X91 BRIGHTON LANE
SUITE 129
BONITA SPRINGS, FL 54136
CINnpt OOMljMe
udkwAddnm
SM BRW ON LANE
SUITE 149
BOMA SPRINGS, RL 34135
Chmpt Oahsms
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OW BINGHTON LANE
129
BONITA MONCK FL 31136
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Address OwW& OeMrMa
Ns & Ad*ws
Tib AAABR
SNNTYLIWENOR NERLYNE
DW/5l13k OP compo".TIONS
Section 17-10
69e1 BRpHTON LANE
SUITE 139
BOMTA SPMMWp FL 34135
PAPMt YNr Flbd Dab
3w3 06 mrm9
2017 OCAM7
3m$ 0413 MO
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Section 17-11
Entity Name: CARE MED TRANSPORTATION, L.L.C.
Current Principal Place of Business:
8891 BRIGHTON LANE
SUITE 129
�jBONITA SPRINGS, FL 34135
Current Mailing Address:
8891 BRIGHTON LANE
SUITE 129
BONITA SPRINGS, FL 34135 US
FEI Number: 46-5258234
Name and Address of Current Registered Agent:
SAINTYL-AGENOR, NERLYNE
8891 BRIGHTON LANE
129
BONITA SPRINGS, FL 34135 US
FILED
Apr 28, 2018
Secretary Of State
CC9997298227
Certificate of Status Desired: No
The above named entdy submds Mis statement for the purpose of changing its registered office or repWamd agmt or both in the State of Honda.
SIGNATURE: NERLYNE SAINTYL-AGENOR 04/28/2018
Electronic Signature of Registered Agent n
Authorized Person(s) Detail
Title AMBR
Name SAINTYL-AGENOR, NERLYNE
Address 8891 BRIGHTON LANE
SUITE 129
City -State -Zip: BONITA SPRINGS FL 34135
(hem6y ra■rfpylhat Me trftnnrnon h,QptW on OF report oditN ycu" r Worr b hue &W@ ¢urate and aua my ebdrantc eynehes ahal Mro aw same kgd etard ea smells under
o•th nlef 1— a msnepNp mnroera msneasraWs WrrMdha6ftYoorrgarryorMe reosPoararwab ampomW b swab a* report as repaired by aa� Fbrhm SYetute ab
that myn•m• appears atrors, Or an Wadenerd NO ar OVWNN anpftsmd. ;
SIGNATURE: NERLYNE SAINTYL-AGENOR NERLYNE SAINTYL- 04/28/2018
AGENOR
Electronic Signature of Signing Authorized Persons) Detail
Date
Section 17-12
"CR wun IT I Arc COLLECTOR. 2NO N- HORSESHOE DRNE . NAPt.ES hLORMA 341 a •(239) 252•i4T1 ... J
VISIT OUR WEBSITE AT: wwmxoi9WUX
THIS RECEIPT BGWM SEPTEMBER 30.2019
[ QCATI OFL 35110 KRAFT RD�` DISPLAY AT PLACE OF Bt1SYrESS FOR PUBLIC NSPECTWX
ZONED: PUD r� o FAILM T000 SO B CONTRARY TO LOCAL LAWS
BUSINESS PHON& 239-599-5606 �'�.w V�
STATE OR 09LIIVT'(UC �
LLC - � �� CARE MED TRANSPORTATION, L.L.C.
�{ {I ARE MED TRANSPORTATION, LLC.
1.6 EMPLOYEES -NO EMERGENCY TRANSPORT I ,, i w., � � VAP KRAFT RD
4- — � . � .� MAPLES. FL 34105
CLASSIFICATION: BUS/VAN OR TROLLEY SER CE 1 �� r
cxASSIFIGnaH CODE 03725101 A t r -THIS TAX IS �_
DATE
This dOmfwd Is a business tax a*. Thb is not oerhTcation that `� �' --'` �� fl2P17�019
If does not Wrra ew i wom b violate AMOUNT 11. DO
�roprdebryl>srp Sir ICEIPT 501-19-00418825
na does i exempt the icmm from arty alher taxes a Permits lhat mai, be w.
Section 17-13
6/22x1019
Detail by Entity Name
Dt,,miON or'Capponminois
Florida Limited Liability Company
CARE MED TRANSPORTATION, L.L.C.
141! 17.1 •tri- •,
Document Number
FEVEIN Number
Date Filed
state
Status
Last Event
Event Date Filed
Event Effective Date
Prindell Address
3510 KRAFT RD
SUITE 200
NAPLES, FL 34105
L41
Drfoji1! I f!j
.al"g'c�;� �0it
3trjCc q flurlein ►rel+wr
L14000051797
46-5258234
03J31/2014
FL
ACTIVE
LC AMENDMENT
04/21/2014
NONE
Changed: 04/27/2019
JhdkW�►d
8891 BRIGHTON LANE
SUITE 129
BONITA SPRINGS, FL 34135
Changed: 08/15/2016
&gistered &Mnt Name A Address
Premier Tax Advising Group, LLC
3510 KRAFT RD
SUITE 200
NAPLES, FL 34105
Name Changed: 04/27/2019
Address Changed: 04/27/2019
Authorized Personl&}j2"
Name & Address
Title AMBR
search.sunbiz-W'nqui yl RM*Ddml9ingdryty EnbWUn &*GcbOnTyPe=lniti d&warchN s n 17,1 4
6'ZZ1?.C19
SAINM AGENORi NERLYNE
3510 KRAFT RD
SUITE 200
NAPLES, FL 34105
Report Yew
Filed Dab
2017
04/26=17
2018
04/28/2018
2019
04/27/2019
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Detail by Entity Name
search.aunblz. T,Mkiibsld+seandW Section 17-15
2019 FLORIDA LIMITED LIABILITY COMPANY ANNUAL REPORT
DOCUMENT# L14000051797
Entity Name: CARE MED TRANSPORTATION, L.L.C.
r•orrent Principal Place of Business:
�4 KRAFT RD
$CITE 200
NAPLES, FL 34105
Current Mailing Address:
8891 BRIGHTON LANE
SUITE 129
BONITA SPRINGS, FL 34135 US
FEI Number: 46-5258234
Name and Address of Current Registered Agent:
PREMIER TAX ADVISING GROUP, LLC
3510 KRAFT RD
SUITE 200
NAPLES, FL 34105 US
FILED
Apr 27, 2019
Secretary of State
8296571295CC
Certificate of Status Desired: No
The above named entity submits this statement for the purpose of changing its registered office or registered agent, or both, in the State of Florida.
SIGNATURE: JEAN MARIE E SAINTYL 04/27/2019
Electronic Signature of Registered Agent Date
Authorized Person(s) Detail
Title AMBR
Name SAINTYL-AGENOR, NERLYNE
Address 3510 KRAFT RD
SUITE 200
bw�-State-Zip: NAPLES FL 34105
I hereby certify that the inknmabon indicated on this report or supplemental report is tnro and accurate and that my ekrcbonic signature shall have the same legal effect as Amade under
oath, that I am a managing member or manager of the tirm7ed gab*ty company or the receiver or trustee empowered to execute this report as required by Chapter 605, Flodde Statutes: and
that my name appears above, or on an affachment with all other like empowered.
SIGNATURE: NERLYNE SAINTYL-AGENOR PRESIDENT 04/27/2019
Electronic Signature of Signing Authorized Person(s) Detail
Date
Section 17-16
IMW
on
Care Med Transportation LLC -Collier County COPCN Application,
Section 50-55 Procedure For Obtaining a Certificate
Section 18
Medical Director's CV, FL Medical License and Job Statement
"Remain Bbased"
Section 18
• S
C;&41014
Transportation, LLC
Phone number. (239) 599 - 5606
Fax (239) 599 - 5607
3510 Kraft Rd, Suite 200
Naples, FL 34105
Medical Director Agreement
Attestation of Medical Director's Participation, Review and Approval.
I agree to act as the Medical Director for Care Med Transportation BLS Ambulance Services.
31
Print Name of Medical Director Signature of Medical Director
Approval Date
I \ F( Z-3 6 a 1
M.D/D.O. License Number
"Remain Blessed"
ThW* you,
Rey yours.
Nsrlyne SaktyFAgenor, RN, CEO
Section 18-1
3/13/2019
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STATE OF FLORIDA ACa
DEPARTMENT OF HEALTH
CI VLgIM OF MEDICAL OuALITY ASSURANCE I
QA7E LICENSE No. CONTROL NC._
Ot1lirl419 ME ��i ! _5S9T50
Tlu MEDICAL OOCTOR
nr.W WOW Itas OW e9 Mq*-TW to of
1M irwe end rules of iras 300 JANUARY 31.2021
IAN MMUFL GUERRERO CORPUS
0--%t ATl'Or
https://mai1.google.com/mai1/u/0/?tab=rm#alI?projeclor=1
Section 18-2
Ian Manuel G. Corpus, MD
701.341.1780
ianco us 11 hotmail.co�n
Education
6/10-6/13 Mount Carmel Health System
Resident Physician
St. Ann's Family Practice
Columbus, OH
9/09-6/10 The CotWno Croup LTD
Vein and Skin Center - Observership
Minot, ND
6/09-8/09 Albert Einstein College of Medicine
Physical Medicine and Rehabilitation - Observership
Bronx, NY
2004-2009 Ross University School of Medicine
Dominica, West Indies
Doctor of Medicine Degree: May 1, 2009
1998-2003 University of Utah
Salt Lake City, UT
B.S. in Political Science: May 2003
Dean's Honor's List
8/97-1/98 University of Minnesota
Minneapolis/St. Paul, MN
Honor's list
Work Experience
7/16 — current Attending
WH Housecalls
Naples, FL
- Skilled Nursing and Rehab Facilities
9/15-10/16 Family Physician
Coastal Physician Care
Naples, FL
- Outpatient Primary Care Clinic
u
Section 18-3
6/15-8/15
Family Physician —Locum Tenen
Mayo Clinic Health System
Red Wing, MN
- Outpatient Primary Care Clinic
5115-6115
Evaluating Physician — Locum Tenen
Veterans Evaluation Services
Brooklyn Park, MN
- Evaluations for Veterans for Disability compensations
4/2015
Urgent Care Physician — Locum Tenen
Governor Juan F. Luis Hospital
St. Croix, USVI
8/13-3/15
Medical Director
The Cortino Group, LTD — Corpus Clinics
Minot, ND
- Vein and Aesthetic Medicine Clinic
7/10-6/13
Resident Physician
Mount Carmel Health System
St. Ann's Family Practice
u
2007-2008
Account Manager
Cortino Mobility Plus, LLC —Medical Supplies
Robbinsdale, MN
- Managed patient accounts and delivered mobility products to
patients in Connecticut, New Jersey, and Massachusetts
2002-2004 Account Executive
HealthCare Recruitment and Placement Initiative, LLC
Harvey, ND
- Recruited nurses from the Philippines, Saipan and Guam and
placed them in Waal communities in North Dakota, South Dakota,
Minnesota, Iowa, Nebraska, Montana, Florida, and Washington
License and Certifications
2015 Florida Board of Medicine - Active
-ME123601
- Issued: 4/02/2015 Expiration: 1/31/2021
2015 Minnesota Board of Medical Practice — Active
-58740
-Issued: 1/10/2015 Expiration: 10/31/2019
Section 18.4
u
2013 North Dakota Board of Medical Examiners - Inactive
-12651
- Issued: 3/2013 Expiration: 10/5/2015
2013 American Board of Family Medicine
- Certified - July 1, 2013
2012 American Academy of Facial Esthetics
- Certified - Botulinum Toxin and Dermal Filler Hands on Training
2012 Laser Physics, Safety and Tissue Interaction
- Certified - Sciton - Continuing Education
2015 AHA - Advanced Cardiovascular Life Support
2015 AHA — Basic Life Support/CPR/AED
Volunteer
3/2013 The Arnold Sports Festival
- Physician Volunteer - Olympic Weightlifting events
8/2012 Pelotonia
- Participant
- 100 mile bike ride to raise money for The Ohio State
University James Cancer Hospital
8/2011 Pelotonia
Physician in charge of First Aid booth
- Bike Ride for Cancer, over 7000 riders participate annually to
raise money for The Ohio State University James Cancer Hospital
2/2008 Tri-State Filipino Association
- Medical and Surgical Missions
Pennsylvania, Ohio, West Virginia
Location: Santa Cruz, Laguna, Philippines
- Volunteered and assisted in general surgery and emergency
room procedures, helped organize community clinic and medicine
distribution
- Organization Of multi -disciplinary team of physicians and
nurses to educate and serve the medical and surgical demands of
the region and consulted with patients on the prevention and
management of diseases
Section 18,5
U
Mw
Memberships
2016 - current American Academy ofFam'
dJ' physicians
2014 American College of Phlebology
2014 American Academy of Facial Estheaics
2014 National Society of Cosmetic Physicians
2004-2009 American Medical Student Association
- Active member in community related health events in Dominica,
West Indies
2004-2006 Filipino Student Association, Ross University School of
Medicine
- Martial Arts Instructor/Student Leader
2004-2006 V"eMamese Student Association, Ross University School of
Medicine
- Active member and organized student events throughout campus
Personal Former Utah State Powerlifting Champion and Worlds Competitor,
Martial Arts practitioner — Filipino Kali, Muay Thai, Brazilian Jiu
chesssu, enjoy travellu1g, hunting, golfing, read biking, piano and
chess
Section 18-6
cli!Le-00"'
7Yra rzsliao r to ti o n� L L C
Phone number, (239) 599 - 5606
Fax: (239) 599 - 5607
3510 Kraft Rd, Suite 200
Naples, FL 34105
MEDICAL DIRECTOR JOB STATEMENT
I. SUMMARY POSITION DESCRIPTION
Helps in establishing medical policy for non -emergency medical inter -facility BLS services
provided by Care Med Transportation; does related work as required.
11. CRITICAL ELEMENTS OF PERFORMANCE
Provides overall medical direction for the BLS Service's emergency medical technician (EMT),
emergency medical technician, and other levels of
maintain control of patient care in accordance with state'drules and r 9guuljattioonns establl hes o
medical policy in accordance with medical control functions to provide uniform benchmarks for
patient care provision; establishes standards for basic and advanced training and continuing
education programs for all EMS personnel to provide uniformity in patient care provision among
agencies; establishes coordination mechanisms with area agencies to maintain regional
cooperation; establishes appropriate medical protocols for all operational phases of the basic
life support programs and establishes policy on the selection and use of medications, supplies
and medical equipment in cooperation with other physicians and the CEO in order to ensure the
utilization of proper procedures and materiel; reviews ambulance calls in consort with the EMS
Chief to verify appropriate medical care provision; promotes and encourages the continued
growth and perpetuation of the all volunteer rescue service.
III. PERFORMANCE STANDARDS
Effectively establishes working relationships with Care Med Transportation
effectively formulates Sound medical policies and protocols; competently sets mid staft
catraining
and retraining standards for EMS system providers; effectively provides advice m the Chief of
Operations in matters Pertaining to the selection,of medical ca
correction, and supervision re
providers.
Section 18-7
•
Transporto6071, L
Phone number. (239) 599 - 5606
Fax: (239) 599 - 5607
3510 Kraft Rd, Suite 200
Naples, FL 34105
IV. KNOWLEDGE -SKILL -ABILITY REQUIRED TO PERFORM SATISFACTORILY
A. Knowledge
1. Knowledge in the general practice of medicine.
2. Knowledge of the operations of the medical services system.
3. Knowledge of the laws and ordinances pertaining to n'iedical services.
4. Knowledge of educational principles and techniques.
5. Knowledge of practices and techniques of report review and analysis.
B. Skill
`. 1. Skill to perform the duties of a physician.
2. Skill in the formulation of medical procedures.
3. Skill In communicating highly technical medical information.
4. Skill in performing case reviews
C. Ability
1. Ability to establish effective workingrelationshlps among Individuals and organizations.
2. Ability to work well with volunteers.
3. Ability to educate others in order to promote better care for those living in the community.
ty
V. MINIMUM QUALIFICATIONS
Graduation from accredited school of medicine with a medical doctor (MD) degree; e
in medicine; possession of a current license to practice medicine in Florida. xPerlence
Section 18-8
l./
Care Med Transportation LLC -Confer County COPCN Application
Section 50.65 Procedure For
� Obtaining a Certlflcatg
Section 19
Refierence Letters
mftmdn w"We
Section 191
Henry N. Braga, M.Div.
Avow Hospice Chaplain Supervisor
pervisor
1095 Whipporwill Lane, Naples, Fl. 34105 - 239-261-4404 - hbraga@avowcares.org
August 24, 2018
Re: Nerlyne Saintyl-Agenor, R.N.
To Whom it may Concern:
-- This letter will serve as a character and Integrity Referral for Nurse Nerlyne Sa intyl-Agenor whom 1 have
known for a couple of years now since I have closely worked with her as professional colleagues for Avow
Hospice in Naples. Nerlyne has always demonstrated the utmost level of professional standard in her
practice with strong intuition and superior clinical skills. 1 consider Nerlyne an individual of undisputable
integrity and moral character and feel extremely comfortable providing this brief analysis of my
observations. Nerlyne is a trustworthy, responsible and caring individual who has already proven to be a
person of utmost integrity and reliability.
1 feel very confident to state that Nerlyne Saintyl-Agenor deserves the utmost consideration in any
endeavor she takes due to her proven history of superior conduct, respect for humanity and devotion to
her profession.
Sincerely,
c_
Henry N. Braga, M.Div. Avow Chaplain Supervisor
Section 19-1
2,W, alms 114u0
N��LES
AVIV';. _11"t 34104
�� +KJ�FAlY;
- V11: 1239)2:44 •n�:t,�
Naples Florida February 26,2019
Dear Board Members;
My Name Is Minoude G. Jean-Louis, I am The President and Nursing Director of Naples Nursing
Academy; Located at 2800 Davis Blvd Suite 100 Naples, Florida. Our Nursing facility, has been training
Care Med Transportation's staff members since 2015.
Care Med Transportation is one of our business partners, among the best Medical transportations in
the South West Florida area.
I am writing this letter, to Recommend the approval of the COPCN for CARE MED Transportation in
Collier County.
Thank you in advance.
Regards.
40" � dna lws, &fN, lely
. _ Mission Statement.
"Naples Nursing Academy, LLC's mission is to provide an excellent education to students
The Academy has the commitment with its students to be successful healthcare professionals"
NAPLES NURSING ACADEMY. LLC - 2900 DAYS OLYD STE 100 NAPLES. Fl 34104 - P: 239-234-5039 -
F: 239.790-1340 - NAPIESIACADEh"GMAII.COM
Section 19-2
Kelly Kinsland, LPN
u (239) 777-2166
Wednesday March 6, 2018
To Whom It May Concern,
My name is Kelly Kinsland, and I have lived in Collier county for 30 years.
I have known Nerlyne Saintyl-Agenor almost five years. We first met professionally at
Avow hospice, where Nedyne worked as a registered nurse (RN) and I, as a licensed
practical nurse (LPN). I have great respect for the care and safety that Nerlyne has for
her patients.
I would not think twice about having Nerlyne providing nursing care for myself, or any
members of my family as a nurse. She has been very caring and compassionate at
providing care for all her patients. She has been a great asset to the nursing team in
Collier county and the community.
Please feel free to contact me at (239) 777-2166 with any questions or concerns.
u
Respectfully yours,
l�
Kelly Kinsland
Section 19-3
Care Med Transportation LLC -Collier County COPCN Application,
Section 50-55 Procedure For Obtaining a Certificate
Section 20
Interfacility Narrative Form & Signed Necessity Medical Form For BLS
Transfer
Lit
UOROIm swe"r
Section 20
BLS
Care Med Transportation Inter -Facility BLS Transfer Forin & Patient Care Narrative Form
ENT Is dXIMLS9"
-- - N0145I ::E GEN:: E3L5 FLDHRFarm
IUASULANCE TRANSFER I Insw'ance
Reason(s) for
BLS transfer
Recant Modicatlons ❑ Pt. States None ❑ Unknown
ALLERGIES ❑ t States None ❑Unknown
MEDICAL ❑ PL States None ❑ Unknown
HISTORY ❑ Stroke(CVA ❑ Cancer
L.O.C. SPEECH 5K1N
_Alert Coherent _Norrnal
Voice _Incoherent —Moist
Pain —Slurred Hot
G
— --
e
Unrespon Silent Cool s —
c.
Y'S DATE
❑ Brought W/Pt. T hi:
List:
❑ Asthma ❑ Cardiac ❑ COPD ❑ Renal Failure
❑ CHF ❑ Diabetes Dim L1 Other
E] Seuure
—No -W
_Cyanotic
_Pale
_Flushed
Does the patient require oxygen?
Normal IJormal `Reactive L / R
—MCS -___Rapid _Dialated U R
_Distresscd Slow _Equal
Absent _Absent _Unequal
Y -Ci + 5 NO
If yes, please obtain a copy of the current oxygen order which must be
signed by the treating/ transferring MD.
e
Call
ti Dispatch
N�
t7
r0
� t'lekrd ftp
y
s5
e]
rn
Dropped Oft'
oxyM only oxygen Via
Liters
EMS Initials
Copy OF Treating MD OXY90N Order - NaTraCJ,nnu a
— — Mask
Non-rebreather Mask
Hn RruT7r- � Repot Mwt Be Given To Receiving NunafFamlly tternbar Ineludng Last YS Assessed During Tranafor, InduM the name of
Mason receiving report In narrative note.
$f.Fi1.SAL tifi Z'R6ATAtEXT 1 TRnxtiport r �-
Thu i, to certify that 1 ■m refusing Treatment /Transport and have been Informed of the risks of doing ao. I
Xx Q
� s�vrs trwwr-me
w;w�li�wme L V
D
Dischuginglfranaferring Nurse Or Family Member Q
EMS License q *-0
Receiving Nurse Or Family Member
EMS L�ceose p U
r0
i
A
i ransportation, LLC
Phone number. (239) 599 - 5606
Fax: (239) 599 - 5607
3510 Kraft Rd, Suite 200
Naples, FL 34105
Care Med Non -Emergency Medical BLS Interfacility Transfer Form
Consent for Transfer
`-, Patient Name:
Date/Time:
■e:
Account Number
Condition at Time of Transfer:
I hereby certify that based upon the information available to me at the time of transfer
by my treating/discharging doctor, the medical benefits reasonably expected from the
provision of appropriate medical care at another medical facility is necessary for my
prognosis.
(Mark One Box)
❑ 1. This Individual has been stabilized such that no material deterioration of the
condition is likely, within reasonable medical probability, to result from or occur
during the transfer.
s.. ❑ 2. This individual has been stabilized for transfer.
"Remain Blessed"
Section 20-2
Care Med Transportation LLC -Collier County COPCN Application,
Section 50-55 Procedure For Obtaining a Certificate
`.J
Section 21
✓ DNRO Transfer Form, Consent Protocol for Code Status During BLS
Inter -facility Transfer
`.J
- 131412,84W
Section 21
ava-
WEENWL
Florida
HEALTH
Patient's Full Legal Name:
State of Florida
DO NOT RESUSCITATE ORDER
(please use ink)
Date:
(Print or Type Name)
PATIENT'S STATEMENT
Based upon informed consent, I, the undersigned, hereby direct that CPR be withheld or withdrawn.
(If not signed by patient, check applicable box):
0 Surrogate 0 Proxy (both as defined in Chapter 765, F.S.)
0 Court appointed guardian Q Durable power of attorney (pursuant to Chapter 709, F.S.)
(Applicable Signature)
(Print or Type Name)
PHYSICIAN'SSTATEMENT
I, the undersigned, a physician licensed pursuant to Chapter 458 or 459, F.S., am the physician of the patient named
above. I hereby direct the withholding or withdrawing of cardiopulmonary resuscitation (artificial ventilation, cardiac
compression, endotracheal intubation and defibrillation) from the patient in the event of the patient's cardiac or
respiratory arrest.
(Signature of Physician) (Date)
(Print or Type Name)
DH Form 1896, Revised December 2004
Telephone Number (Emergency)
(Physician's Medical License Number)
r
-------------------------------------------------------------- i
PHYSICIAN'S STATEMENT ---------------- r
N*mw SMAd State of Florida N
I, the undersigned, a physician licensed pursuant to Chapter DO NOT RESUSCITATE ORDER
458 or 459, F.S., am the physician of the patient named O
above. I hereby direct the withholding or withdrawing of
cardiopulmonary resuscitation (artificial ventilation, cardiac P'atient's Full legal Name (flint or Type] �paw — -- U
compression. endotracheal intubation and defibrillation) from ♦�
W
U
Jim,—
Aof
i ransportation, LLC
Phone number. (239) 599 - 5606
Fax: (239) 599 - 5507
3510 Kraft Rd, Suite 200
Naples, FL 34105
Care Med Transportation DNR & Full code Protocols During Transfer
Care Med Transportation will provide only BLS Non -Emergency
Interfacility Medical Transfer. Care Med Transportation is a non
emergency company, therefore does not provide any emergency medical
care, beside stabilizing a patient according to his or her emergent medical
need during the medical crisis until an ALS emergency ambulance arrives.
In case of any emergency that might occur during transfer between
transport from one facility to another, Care Med's protocol is to follow the
same life saving measures that were implemented at the
discharging/transferring facility prior to discharge/transfer and signed by the
patient or appropriate representative.
A Care Med BLS Non -Emergency Medical Transfer consent Form must be
signed by patient or authorized representative prior to transfer.
See Consent Form on next page.
"Remain Blessed"
Section 21-2
on
CM
Transplortation, LLC
Phone number. (239) 599 - 5606
Fax: (239) 599 - 5607
3510 Kraft Rd, Suite 200
Naples, FL 34105
Care Med Transportation BLS Services DNRO (Do Not Resuscitate
Order) Protocols
Per the Florida Department Of Health any patient wishing to be a DNR during
Inter -facility transfer must have the Florida DNRO yellow Form for transfer, otherwise
the patient is automatically a full code during transfer. (Please see an example of the
Florida Yellow DNRO Form and the Florida Department Of Health rules and regulations
pertaining to the "Do Not Resuscitate Order DNRO).
"The Florida Department of Health works to protect, promote & Improve the health of all people In Florida
through Integrated state, county, & community efforts".
Section 21-3
ri
li
4
AOr
r
Transportation, LLC
Phone number. (239) 599 - 5606
Fax: (239) 599 - 5607
3510 Kraft Rd, Suite 200
Naples, FL 34105
"Remain Blessed"
Care Med Transportation BLS Services Full Code Protocols during
Inter -Facility Transfer
Background
Any individual in need of medical attention or requesting medical assistance of any kind
being transported via Care Med Transportation is considered a patient and can only fall
within 1 or 2 of these categories as per discharging/transferring facility:
1) DNR
2) Full Code
During Inter -Facility Transfer any patient without a Florida Yellow DNRO Form is
automatically a full code. If an emergency arises during transfer all efforts will be made
to sustain the patient's life according to Care Med's Medical Trauma Protocols until an
ALS ambulance service transport arrives.
'Remain Blasted'
Section 21-4
i ransportattort, LLC
Phone number. (239) 599 - 5606
Fax: (239) 599 - 5607
3510 Kraft Rd, Suite 200
Naples, FL 34105
Reason for Transfer:
Risks of transfer
include:
All
transfers have the inherent risk of traffic delays, accidents during transport, inclement
weather, rough terrain or turbulence, and the limitations of equipment and personnel in
the vehicle.
Benefits of transfer
include:
above risks and benefits of the transfer have been fully and completely explainedeto the
patient or the responsible party by the physician who is certifying the transfer.
Physician's Acceptance:
I certify that the above-named patient has been accepted by
Dr.
at
Accepting Facility
Sending Physician's Name Printed
on
MOMIn Bless*C
Code Status
Section 21-5
Nurse's Signature
Nurse's Name Printed
� Portation, LLC
Phone number: (239) 599 - 5606
Fax: (239) 599 - 5607
3510 Kraft Rd, Suite 200
Naples, FL 34105
W Patient/Guardian Consent for Transfer:
I request and consent to my transfer and have been informed of the risks and
benefits involved in the transfer. I authorize the release of any medical records or
information to the receiving facility and/or physician. I acknowledge that I have
received medical screening, examination and evaluation by a physician, or other
appropriate personnel, and that I have been informed of the reasons for my
transfer.
_ Patient/Guardian Request for Transfer.
I, the undersigned, am being transferred at my request. I acknowledge that I
have been informed of the risks and consequences potentially involved in the
transfer. I hereby release the attending physician, and other physicians involved
"Remain Blessed"
Section 21-6
rr
rr
r
1001,
� .-art-sNartation, LLC
Phone number. (239) 599 - 5606
Fax: (239) 599 - 5607
3510 Kraft Rd, Suite 200
Naples, FL 34105
in my care, the hospital and its agents and employees, from all responsibility for any ill
effects which may result from the transfer or delay involved in the transfer.
I understand and agree for Care Med's transferring team to follow the same code
status I have now at my discharging/transferring facility. I fully understand that
there will be no deviation from my current code status in order to better follow my
life saving wishes.
I am a Full Code: YES
NO
I am a DNR and a copy of my DNRO will be provided, and I fully understand that
without the DNRO form, I am a full code patient: YES
NO
Signature
Print Name
Date
"Remain Blessed"
Time
Relationship (if not patient)
Section 21-7
i
U
,purtation, LLC
Phone number (239) 599 - 5606
Fax: (239) 599 - 5607
3510 Kraft Rd, Suite 200
Naples, FL 34105
Legal Guardian (Please Circle)
u Yes No Parent/Guardian Cell Phone #
Witness to Signature
Print Name
If the patient cannot sign or If any of the above signatures cannot be obtained, explain why:
"Remain Blessed"
Section 21-8
r]
Physician's Signature
u
Print Physician's Name
LMM
Cfl
.u.I,3jVUrtation, LLC
Phone number: (239) 599 - 5606
Fax: (239) 599 - 5607
3510 Kraft Rd, Suite 200
Naples, FL 34105
Date and Time
"Rmuln Blessed"
Section 21-9
Transportation, LLC
Phone number: (239) 599 - 5606
Fax: (239) 599 - 5607
3510 Kraft Rd, Suite 200
Naples, FL 34105
Trauma Protocol For Care Med Transportation During BLS Interfacility Transfer
Stabilize and Ca//
911!
What is Care Med Transportation BLS (Basic Life Service) Service?
Care Med Transportation Basic Life-support ambulance: Ambulances that are equipped with
appropriate staff and monitoring devices to transport patients with non -life-threatening
conditions as these ambulances can only provide basic life-support and non-invasive services.
Section 21-10
�r
rr
0 i ransportatton� LLC
Phone number: (239) 599 - 5606
Fax: (239) 599 - 5607
3510 Kraft Rd, Suite 200
Naples, FL 34105
Care Med Non -Emergency Medical BLS Interfacility Transfer Form
Consent for Transfer
Patient Name:
Date/Time:
DOB: Account Number
Condition at Time of Transfer:
I hereby certify that based upon the information available to me at the time of transfer
by my treating/discharging doctor, the medical benefits reasonably expected from the
provision of appropriate medical care at another medical facility is necessary for my
prognosis.
(Mark One Box)
❑ 1. This individual has been stabilized such that no material deterioration of the
condition is likely, within reasonable medical probability, to result from or occur
during the transfer.
❑ 2. This individual has been stabilized for transfer.
"Remain Blessed"
Section 21-11
NVA
Care Med Transportation LLC -Collier County COPCN Application,
Section 50-55 Procedure For Obtaining a Certificate
Section 22
State BLS Equipment and Supply List & References
8%maln BNssW
Section 22
Care Med Transportation LLC -Collier County COPCN Application,
Section 50-55 Procedure For Obtaining a Certificate
Section 22
State BLS Equipment and Supply List $ References
See copy of FL Dqmtmau Of Health Supply list as provided from their website.
"Itorndn
e
Section 22
17. Hand operated bag -valve mask resuscitators, adult and pediatric accumulator, including
adult, child and infant transparent masks catpabie of use with supplemental oxygen.
18. Portable suction, electric or gas powered, with wide bore tubing and tips which meet the
minimum standards as published by the GSFA in KICK -A 1822 E spec; fications.
19. Extremity immobilization devices. Pediatric and Adult.
20. Lower extremity traction splint. Pediatric and Adult.
21. Sterile obstetrical kit to include, at minimum, bulb syringe, sterile scissors or scalpel, and
cord clamps or cord -ties.
22. Burn sheets.
23. Flashlight with batteries.
24. Occlusive dressings.
25. Oropharyngeal airways. Pediatric and Adult.
26. Installed oxygen with regulator gauge and wrench, minimum "M" size cylinder
(minimum 500 PSI) with oxygen Flowmeter to include a 151pin setting, (not required for
non -transport vehicles.) (Other installed oxygen delivery systems, such as liquid oxygen, as
allowed by medical director.)
27. Gloves - suitable to provide barrier protection for biohazards.
28. Face Masks - both surgical and respiratory protective.
29. Rigid cervical collars as approved in writing by the medical director and available for
review by the department.
30. Nasopharyngeal airways, pediatric and adult.
31. Approved biohazardous waste plastic bag or impervious container per Chapter 64E-16,
F.A.C.
32. Safety goggles or equivalent meeting A.N.S.I.287.1 standard.
33. Bulb syringe separate from obstetrical kit.
34. Thermal absorbent reflective blanket.
35. Multitrauma dressings.
36. Pediatric length based measurement device for equipment selection and drug dosage.
Sufficient quantity, sizes,
and material for all crew
members.
Sufficient quantity, sizes and
material for all crew
members.
One per crew member.
RulenraEing Audiorily 381.0011, 395.405, 401.121, 401,75, 4111.35 FS Luw Inlplenrented 381.0011, 395.401, 395.4015, 395.401, 39 5.4025,
395.103, 395.401, 395.4045, 401.23, 401.24, 401.25. 401.352, 441.26, 401.17, 401.281, 401.30 4'01.31, 401.321, 401.34. 401.35, 401.41, 401.411,
40/.411, 401.1211,£ Nistary-Nest, 11-29-82. Amended 4-26-84, 3-11-8j. Forurerly II)D 66,49, .amended 4-12 88, 8-3-8,4, 135, 401. 1,401. , 1.
16-97, Formerly 10A-66.049, Amended 8-1-98, /-3.99. 11.19.01. 12-18-176, F-ur,nrrly 64E. 2.002, Amended 9-2-09.
Section 22-2
64J-1.007 Vehicle Permits.
(1) Each application for a ground vehicle permit shall be on DH Form 1510, 04/09, Application for Vehicle Permit(s). Each
application for an aircraft permit shall be on DH Form 1576, 4/09, Application for Air Ambulance Permit. These forms are
incorporated by reference and available from the department, as defined by subsection 64J-1.001(9), F.A.C., or at htip://www.fl-
ems.com. All applications shall be accompanied by the required fee as specified in Section 401.34(lxc), (k), F.S_
(2) When it is necessary for a permitted vehicle to be out of service for routine maintenance or repairs, a substitute vehicle
meeting the same transport capabilities and equipment specifications as the out -of -service vehicle may be used for a period of time
not to exceed 30 days. If the substitute vehicle needs to be in service For longer than 30 days, the agency must seek written approval
from the department. An unpermitted vehicle cannot be placed into service, nor can a BLS vehicle be used at the ALS level, unless it
is replacing a vehicle that has been temporarily taken out of service for maintenance. When such a substitution is made, the
following information shall be maintained by the provider and shall be accessible to the department:
(a) Identification of permitted vehicle taken out of service.
(b) Identification of substitute vehicle.
(c) The date on which the substitute vehicle was placed into service and the date on which it was removed from service and the
date on which the permitted vehicle was returned to service.
(3) All transport vehicles permitted to licensed services must meet the vehicle design specifications, except for color schemes
and insignias, as listed in United States General Services Administration (GSA) -KKK- 1817, Federal Specifications for Ambulances
as mandated by Section 401.35(1 Xd), F.S., applicable to the year of the manufacture of the vehicle.
(4) All licensed providers applying for an initial air ambulance aircraft permit after January I, 2005, shall submit to the
department a valid airworthiness certificate (unrestricted), issued by the Federal Aviation Administration, for each permitted aircraft,
prior to issuance of the initial permit. Aircraft replacements are subject to the initial application process.
(5) For purposes of Section 401.26(1):
(a) Water vehicles with a total capacity of two persons or less are neither transport vehicles nor advanced life support transport
vehicles.
V (b) Water vehicles with a total capacity of three or more persons are neither transport vehicles nor advanced life support
transport vehicles, if:
I. Staffed and equipped per the Licensee Medical Director's protocols consistent with the certification requirements of Chapter
401, F.S.; and,
2. Reported to the department with sufficient information to identify the water vehicle and to document compliance with
subparagraph I„ above. Such report shall be updated with each license renewal.
(c) A transport vehicle or advanced life support transport vehicle that has explicit staffing, equipment and permitting
requirements under Chapter 401, F.S., and other rules of the department cannot fall under paragraph (a) or (b), above.
Rutemaking Authority 381.0011, 401.23, 401.26, 401.35 F.S. Law Implemented 38/.001. 381.0205. 401.13, 401.14, 401.15, 401.1.il, 401.16,
401.27, 401.30, 401.31, 401.34, 401.35, 401.41, 401.411, 401.414 FS. Htstorj -New 11-29-8:, Amended 4-16-84, 3-11-85, Formerly IOD -66.53,
Amended 4-/248, 12-10-92, 11-30-93, 1-16-97. FormerlY IOD -66.053, Amended 1-3-99, 12-18-06, 10-16-07, Formerly 64C-2.007, Amended 9-1-
09.
Section 22-3
DEPARTMM-r OF HEALTH -EMRRCENCV NIEDICALSERVICE4
5rr►!ec
BASIC LIFE SUPPORT VEFIICLE INSPECTION REPORT (SECTION 401.31, F.S.)
Name;
County., T of Ins InsprdtoR Dale: / PI 0:
Veltiele Information: OTraa licetlon: Olaithl O Reinspee0oo O Random O Colnplalnt OAnnotmced D Unannounced
VIN sportONon-Tnusport Udtli Year/Make PerodtType PetrtoltM
IeePrcyir■r Codr■-
1 ' hear rust■ inspection criteria.
1a' Iters corrected &I blWaion w arthro criteria 3" Lfr■Irr■� cqr.�. r.rJr■I a.spPltn, Jrytr- r�-fen:t a
I ' Inrrr■edlse alSOrets rq■�■r■r, me,ie■1 los * Or I
'arse■ nor In eanp0ance with irnpegion criteria 3 ' Miniosl "s• d^' w ncordt or In`aKdrrts
�e q■ipes, rredieal aaPMiea. rtsards or Prrsedroes
E11L.-L
r:111T1P,h%VDRIVFJI-IITiFTCAT[N�Ia Efa
credentials: Section 10117(!)
Irl1 101.281. R.S. UmNRi117" One EMT and One Driver PI
QU 90t CM FATS fSect;am 336 -ad 401. TS.. Cha 04" 64J;A I-1, F,A.C. orad
Know Pw
I. FAt■rwr Syfetnr
FEW— I-I&I-
&I trial h=ht% Ihrah m■e low heals+
_rT_ wpr.lt
V •. Ikake Light.
r. aras.yr OW"d srrfibk *www dreitc - -
3 Iter■ an -
i Wadddekl tnpsry
i Tan
i Yehrrk frn ■t roar anJ decor
7. Tse-udy rsdm oon■n.nic�hon - radw rw
A. Hmmp (nband pisx nar"nncno l -- - -
[A -MM"
Wrr f7tf5 wnita rgcoI f lineAOC Trr ntwrjwlIthrrs hfly chop
achov, opts Petgmil,ela■rterurcly
ev rid tido viewatMray ant wirvl1r 1AMS POUT VRiI ICLE RXQUIRh atld 1ra4 a>rNcltasat dyer vr%M
Nry tleeIII nwd w" inn" crI nw mkd IV koidcra- '� NPmkpkmg raga■
S. Qea low Pty rat, ^-
6. Sww borsch and lhesr" a of W., bek .
sed ra Micd in br■ctm 41inrmym
Option 401, FA. ml
- . tar, ors
1711E pw of Eltndagr Shc4n - - - �
.Or ad vdL patlerll rtgoinir _ .ni3t tad mrkle
'Drat mh Mord Prtbere [ufrs inLvx, Pcdimre. and aJal1
Otc 101-ths fie. Itrrlrm n: arf! .dv[r
Br,aw
34cru. Iru rcgc.i W ■n ra...nYrry,■rt n*ic'.ti
Pdiows w■irb waaTmer�evers aId plllpuYasn pr dtipvsabk em k
n3d[Sal F ere piaurrr• Hear rrOulreW un torn.
Of dt¢rabk hte■krt n 1■rnml ra■3 rrnre
0. One k" 1110 board and dope stralp or egsigieer.
I. Orr short +rarer boo rJ and I`u uropt m egwralrrrr
'• Dec esti out> 4 pcdomr cavil wtmtobilualian device (CID
(*& service This ayipmva) nm be in writing and ewk ■v■lable approved by w 1 medkar dircat■t
�vierrt, y tion pr■vjt{rr fur Ibe dWartent w
t S,n.rprldeii ter Rdenl Je�.pra rlrrnrr"I'tat—oflrale■rC patreatt,
__
[ a
I Tit oxygene000daesith one
1-D- or'E'tylir, wnyW*W sodP■, Eadr
tsdc ■wry Nae
S Facfl tnmprrm oxygen morals; aduh• eluid.nd infra sats. *idr e
:6 Sts 6FPedr=rr. and aduhr poral rnrn■tae with ngrng -
:7 Ont rub I11wd Wonted bag•vxlvt mask murnWv; adult and Fednluie
uh- cf >dd rad refer trtl¢ "', mnhs r hk oiMC re1d1 Mc�Mx• Irveir.,l�rq
I Ont portable ea
>uni 4 e ar,, WIN PMVv rd. with vide bora
n �y 'r rtartN+sk a tivt j SA a KItK-A-:1±? r *I which meet rhe
ward tan of ettrletily lr>b■aI dt'rkri
0 Ora 1111411, aary womian'I IPadie w onto AWhf
!.
Oft yolk rbwwsntaf hk b NKIW., al mnmru but! n
IamQt a mm -p m et >n• lir. den7t aNxwes a Icahpei Ind cad
t Ust,m drnr�
t3 Otte (ULII thein nsr b■1lorta>_
.I Occhis" dma.rs -
ns A,tarwal arra'+-, atq _"-ffcsl arrY•aya. f L'imm iltl �4h111
:rr OIr visa(ie1l o4yge■ wish rI ainior gauge and
�+y0set deliver] tytts■t, mot a 1 wrench.minirman "m'six e]tr■drr. (Doter wstalw
a'rd,R sed ■ruk¢dt in Its �i'/�t. a 4110101 by exdk■1 director. Thio aPpmval nom be m !
:t Sq.7rcimf ��Iernevievno
9Z;t nfgleves -w- &le On P"I tt■reirr Pro[epriae from bio
rcrrWnt IurxJr for all eetw
a. SnrGc me q m w"or." for d: Cre''nr r hers -Fare h
rn.rni.s - b■Ih Animal end respiraw"
o+v■Mivoirtg e}o� lura
I1 11'.nf.'Andldawae-- t.dct 1..ck 11d nrtrr er.lpc Inrd-
�uee r- anrf Moe u4sl npf eerrv■I rsdlan u apprwN in r � .
as'+rlahie frr tpvlea dr 'eery by herr n �licrd dreenrr
II- \iC[ilCAL EQU Frail MW FOR TFS If faf: (cLI.fnrr i4J-1. F.A C., sed l NK.A•ISII
teach qr awr slryn-a5nrt t inls,te . N.Maerc . aawf sdµu
't'1'^"� beduawdlxa
I brass rl sesrre t i"lrtalen ",
•sue rlrAic bal or inrporvtopa W icer
— ] i Prdiaptc ten heard pa Chapter 84J•1. F. ALC
M. dn�et fv
. ikarr i, 14.17. ii ■Ito 26 w atrtiun II time N ",dV'
�ete�ann_rrx t9+T� kketinrt� and de.� ossa
oilEU1CAL SU TUM AND EQU[Pa[FJri Whopfer it.1-J. F.A.C» CSA Ktf,IC,A-
1021
t? t7we per 111111,; 111 gugglca u' It=kK ^�,'tisg AJYS[7.g7.1 gruo4rl
1 !)e.bulbsyriege+rWrekcrrameb.innullot
Lh—ng u■d EIvWp ,_ -
;i _BZWVnr,
k aolb+rF[aiae. ■ih or pbmK tops
._-
4 One daTsal ■beo[seel orliKiLye bltglryk . _— _
f Tn„ -
garrr.•p■rlt.mysix - --- • _
Simile v
arpkr=.aII■■ {R
;_ .._ -
4ei1
7nnrgldarbrrrgr,
VENERAf.SANiTA
ddcle rad C■■te■ O SaalS■ m
ayOUewtltsry
.M slaeF
e
I, the MIT Of neII rt}rrstur■kl e ( tae ■ *e d,, ■rk■■wkdge resdPt of. t'Pr ■f tib t■rltmlto
■w ■tart at sir dedrk■Nes (If any)." that ta0rn
■■Ralhe, ■Ppnc" r■ppknreid hoprI
ad■■dtnla■d apart- and ttrreedve ■oily
Iln■akk..■ wr6W i■ Senior 491. Fl., ted Chepler ""' F..IC. C y tf 1■ rr
1* xrrtet riot drgekacln MIH■ the established time bases wry pbkcr Ik trrrin god ht neh■rt.N re PP�k■bk4 Is rddhim, l
Jet,
'p- Wettl■a tapas W C■rraesNY Atlly Sta1t■w■1 Preteawkn IIs■
Rrt'elved bv: Ngjd1v, u'dAhhtntlrr ■sire ud
Section 22-4
I I I I P. QF FLUteiUA
OF - EMERGENCY
SERVICE RECORDS AND ACDEPARTMENT
IL TIES INSPECTION
pi3i.
Servlcr'ianlr:
REPORCP^(Sg,pry RS,)
—
—"— _- fnsprcrian darn:
-�_ f hanr: I_
_
Type of lospeelioa: [3 Isiltlal O Rtiaspeetiea O Random O ConlPlaint OAnnounced ❑ Unannounced
Lternse Type: -1 1 ranslfnrl ❑ Noatranspert Date orust Inspation: r
Instim ion Codes
- _ I.r[rnsr Expiratlun I]atrr
1 - Item meets inspection criteria.
-
1 R - Item corrected during inspection to meet criteria.
1-lL�fesavin ui
8 pmeI medical supPlios, drugs, records or procedtaxs
2 -Items not in compliance with inspection criteria.
= Intrnnediaie supportequipment, medical supplies, drugs, records
Or procedures
I - Minimal support equipment, medical supplies, records
or procedures
i. Anm l if 151 HA I I V EAND It ECURPS St URA GF6 I Clraprrr 6411. f•_4C.1
t. arfnrd. is Ars es•ad lot wy.
_
i. ,Accords Ann=e rsr i Aran
_
mrco
I!. 1115 tsmi. dM t, FS.. Chapter dµ1. F,.L(y -
I. Ilewa err W acrd 4 a culrrare [rnfr.ikd
. - S iearrJ sad ale cnndafvard} iotaNar,
I. Creraw nt'r4e Retrdaa a dletday, ILUteltr 641. 1. 11
!. The ars, is clesw sad saellary"
1'akktwlAh, A rtecards LChaptor Nl•1. F,AX4 To iwdmk:
LOhserrr steles fWlnrl r uir
ae r9 teary ser eaarwieJ rxpnaarn arc peke an;
A.
I. Tse ngrrrrala uleeJ In IYaaa lei akaTa are trlaa art.
e. VrrMkrd.n of veiltMprnrk.
L ilrtlral rNretiw W reMMersd alerree areal rlth DEA {Ch. rr i
G 1Yritlaa aperot pt 11-1. F.rLC.I
o f prerrJern far 16e
J. 1•ra+ilin laryc Im feral, ick.pr" 64J- I, F.A,CI
alaraAe sad Ilrndfia= of grids and walk:eie.s Aper Err the
hilWwi
a, Prraaaatl lercoinhi fat rock UIT, grin motlk fChoptrr 6.11-1, F.A.C.}
I, Srrwrf eI Maredam.
7. larlwdn;
L lltwe scared to a sern.rc inn cry lid Ivrallrr leen - f lralrll and air caadinarrdl
A. parr of empierneae,
-
a-prcrdafiRlMn=.
3. Delcnxared -r rsgtret hems stared In mar, q.
q area,ae rnsfrom nahielteenL
t rarealary
-
L•- e'rrrtor pro}nrienal rrrHarorinn.
Pnrrelvee•
D. Drtaneemitm al Mealtime" or IM i!® D.O.T, Air Atedeal Cis+"
D. {Yrleeer spar+++^! gl'a'rdarn car the ll-r-je aid baadalnt of canrrsard rahatanm apKl14 ere
ftdNwl
National Slandard CorrkalemAdva ono for hnmedk Cmc member
+• 3earap prxrdtltr� �•� - -
Snn t!~rr 64J..A!j
S. an drlrw reMI (fer cosh per Srcdae ea13M1tIJ, Fa1,l
_Tr lae1 pdr�9rasen_ "rat wfr.rle ro A. p. C-
1pe-
L TION /talIfaaa sial have aetWs fa ralNnllyd talwunn•�
RII. la Arra is J.
Nor adncJ dlla alrvbd a Mal railed sahsnarr4
i^rrnl
3.511 chaa� +rf pra[adrraA let, sahlsta► -
... -- -ii -
C Free from physkal w mensal defect n dlsena Hat world Iwg-Ir �
4. I'rreedam to be as far the danmeatado- V ase. dlrpaaal -f wren sed nsxptl9 •t
rddrles wkb controlled nhrtan eL
— �- -- - .
dhUT Is drive.
_
S. hwed.rce atad far Invenlr y dhcrepa^tIH, - -
h, nrl.s,K record +erlaralra.. ---
1~ Patna VW lei Ones `D" rr ciao ritlr }knaa
- F. VreiTr rkrt lir fMtaw soar: colter seta
— rd it cunt retied 1uhuames:� - --
I. Slpl-a;t er'eards -n mataraiaed on fdt at the iae-lloa when Se raalrailea rahsiaelcea
F. it Iralany A carr apenlisr ore nHek � [f kaar LY.tI,C.
-ra
Z ANinJ r u.emorm rod
C., tirOlnara - rod a Red hf A-er ct C— First Aid dmj abirnnl
�1 kir raid w iN rlratreY,
- rrnrdl arc a AIIIIIned at kap
}. 1lrrardl err rrla+arilpad aeparayly frpn
It. Ars-aexl a valkl Aaarrkan Rrd CYras wAom k lf"n
olk" nswdt, —
--- --
Arratl-rt-n CAR or ACLS rarvL
YOTY:
a Cgnra r^r.11 aalwlhnlia�-r wkea asrth-rimfinn Lv ^w"'i dinatr-r NPI 64J- 1. F,A-C.I
I(
Carseat FJ1fT K p-r-medlt ""latadaR it erldtars of Meeh site -i 1h
g
ferma A, C sad C spars. LScrNor •tI1S1' 1 rS
�-_
t. Mnw.rdkal Hoer nprrann FsaMarsr fstet►ta ]il.aa, FS sad
ladvalf, lata GI
Or (s
:. Aledinl ptrnfar [Setrlan 641-1, P,w.C.}
F
P r1.C,1 it
A, Q-111k011.ns: Crrreat ACTS nrlflleNlva ar board nrr1111 as in
A- haps" kawrlllae
IL Pr.prr
_narrarn r7r7 rnedlrl negCbr ur ill- F.I.C.
�
It heron ae
and rrapttkfl WHO (Ch War "J-1, KA.C.1
_
a pr.pw dly.rr -
I, N -.a lrlte.ly> vprr-sl In proce.lur,r far Ant kar scram
-
l0. Cats edrra
Acv dlrastrr plea Intetn[rr
1. wHlern gaalRr anrrnee m colloF
pe'� aP C prared.rex Ikar ngake iia
hath local and rrt4onal dirar[n phn fCb.pr,r 64i-1,
• �'
Rer.1n
it, AJ I sad rediatNr CID asp corn !a trrlil by medical dlnnor lCkrpflr 641.1. F.A,C.I
a. 1lraarpt rnirw of r.a rrparq,
I% ff all P,IILS prerldsr alin4lat aA
k Dtrrn ahr"rssel.a at iraneNOAe
ah inbl14ncr Hcrare a pas
fel -da nraed r ir'alra%k that a !a cellar 101.171 FS aaJ mll�diasurrnr, Ike
1, F.A.C.
A. Swmrerary fRWani for overdue stress f4 whoa radla ram roe nk al loan
3- nwaf.lion of avtWrmOlin of a1 akar.-
L 4ncwnArelted af�p.rtlrlpA/!an to rlUaee eaetraet Naar vrkk E8r5 fkld lard
rnatYat
w whra surra, LA-" be isrowd, he sslaldnitd.
Dae.rrsw°rlwa of Rq ii daoe er.r� 1S lr`leW ,r}ilr Annear
1hvNders for a ad arm V li boo
tv .^el ,.res
C. $.fir cnnrdnee he rarlrnk• .Jr._ �a Ilow't l"hon.
7. firrrrtrr•f, srmarie sed rarrglr prated."" tar
1.101 cmbtrsblp Ol roc gAat, wlt ilathl eatbeOl eros 1111 Oil I I axdlra! d{rrrear, E
r nArtirr i4d a�I�y
wlMirsenvao, Rahe and lnwlrabed
mbrtancn 5retngd F a>.d Cha fm iii 1, F.A.C.
i�..._ 1.
�da.siatntor rfiw lit! b.,nl},
J- wrirrew wFer Praredren
A. ❑Wtnr if sir MAI drq§I"; regi fa medaca ftM_ rad 0olds ars king an",
3. Meer Vp held 1111 11arfr la rs.kw
1. i in-I&I area it arrrrad try . Inc" arrrbawisar.
ukry polcin, procedures. aausnal
- �1 �-iaddf ca�arrAI "I, i�q�} oilrier �e1! pro c durrs. wturreum. aaMx
Ja al
Z AI! items an Iarrvearlyd ■e lease awafi y
d. Safrll .µAlt Ira.ih r-aldearleafed 1- aA Pd., Ir prsr
A net "MAI rd ar expired terns ■n N-nd In a quraadee acro, sepanp Tracor
X ifhalrn err meNfaes rreardta uo nMd ,Io ^Md d an file car 7 Zysur.
sea Me llrmr.
�,�
-
-comments:
--- --
Irife
he
Sutemen e� Keble' h stave of t aabove service,
ery the defidoneie receipt tN a COPY of this inspection narrative, app6caI supplemental Inspection
Ppl )
reports and cpR�ft action
C Ivry) arra understand that failure b Correct the deficiencies within the
s,figoct the service and Ms authorized representatives b administrative aK1lon
and Corrective Action Statement Received by:
rind penalties as outlined In Section 401, F.S., and Chapter 64.1-1. FA shed time will
Ycrson in Charge:
I spores n r
COPY of Inspection repoA
in';pected ler:
Section 22-5
Section 22-6
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Section 22-6
Care Med Transportation LLC -Collier County COPCN Application,
Section 50-55 Procedure For Obtaining a Certificate
Section 22
State BLS Equipment and Supply List & References
References
l'U77XrA7AA.Xi M-PrIl- M-- HIM
•l l• •Il' .1 - 1'= fill
Collier County EMS Department
M
"Remain Blessed"
Section 22-7
u
v
Care Med Transportation LLC -Collier County COPCN Application,
Section 50-55 Procedure For Obtaining a Certificate
Section 23
Communication Protocols For Care Med BLS Ambulance
Non -Emergency Interfacility Transfer
Section 23
rtation, LLC
Phone number. (239) 599 - 5606
Fax: (239) 599 - 5607
3510 Kraft Rd, Suite 200
Naples, FL 34105
Communication Protocols For Care Med Transportation BLS
Non -Emergency Interfacility Medical Transfer
As discussed previously with Director Summers and Dr. Tober, we will be using a phone
number as our main telecommunication system, but we will also have the required
Department Of Health Communications system in case our services are needed by the
EMS county during an emergency event.
As a community based service we also have to plan for emergency events.
In 2017 during the hurricane, it was extremely difficult for our colleagues to
communicate with us. As we move forward with our planning, we do realize that we
have to have proper protocols and proper planning in case of any emergency, where
our services might be needed by the Collier County EMS Department in order to
overcome any emergency we might have to face together as a community.
"Remaln Blessed"
Section 23_1