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EMA Agenda 08/12/202015.A.2 COLLIER COUNTY EMERGENCY MEDICAL AUTHORITY (EMA) AGENDA August 12, 2020— Wednesday 9:30am 3299 Tamiami Tr E, HR Training Room 1. CALL TO ORDER AND PLEDGE OF ALLEGIANCE 2. AGENDA AND MINUTES a. Approval of Today's Agenda b. Approval of the March 11, 2020 Meeting Minutes 3. OLD BUSINESS a. Performance Measures Update b. Distribution of EMA Bylaws 4. NEW BUSINESS a. Ambitrans COPCN Renewal b. MediCab BLS Interfacility COPCN-New Application 5. FIRE SERVICE DISCUSSION 6. STAFF REPORTS 7. PUBLIC COMMENT 8. BOARD MEMBER DISCUSSION 9. ESTABLISH NEXT MEETING DATE a. September 9, 2020 at 9:30am, 3299 Tamiami Trail E, HR Training Room 10. 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The Authority is an Advisory Board to the Board of County Commissioners with the following objectives: A. To assist with issues affecting pre -hospital emergency medical services within all of Collier County. B. To hear issues associated with pre -hospital emergency medical services when requested by a participating agency and make written recommendations to the Board of County Commissioners and involved agencies. C. To work to improve and enhance pre -hospital emergency medical care within Collier County with thorough study, education, and system -wide participation by the response agencies and the local medical community as noted above. D. To make its special knowledge and expertise available to any and all agencies upon request of the governmental board or agency when so charged during regular board meetings. E. To serve as a catalyst to effect cooperative arrangements for improving and best utilizing emergency medical resources in Collier County, utilizing the resources of all municipal, dependent and independent fire organizations, 911 call centers, law enforcement agencies and the public. F. To make recommendations regarding first responder programs, training programs, communication systems, and other appropriate facilities and services that positively impact on the delivery of emergency medical services. G. To assist in the development of Interlocal Agreements and appropriate standards of care provided by all agencies so as to adjust levels of service commensurate with the needs of citizens of Collier County. Such efforts shall be in a cooperative fashion so as to implement those changes consistently countywide by all appropriate agencies. H. To perform or assist with any other function or duty as requested by the Board. ARTICLE TWO — Membership, Terms of Office, Filling Vacancies Packet Pg. 2358 15.A.3 A. The Public Safety Authority will be a five member citizens committee with members having no affiliation with any hospital, fire district, EMS, municipality or Collier County Sheriff's Office. B. Terms for all Authority members shall be four years. C. Filling Vacancies. When a vacancy in membership occurs, the staff liaison will ensure the vacancy is publicly noticed. Applications will be forwarded to the staff liaison to review for qualifications. The membership of the Authority shall review applications and make recommendations of appointment to the Board of County Commissioners. The Authority may interview candidates at a scheduled public meeting. D. Reappointment. Members are eligible for reappointment. The staff liaison shall provide the Board with attendance records of all applicants seeking reappointment. ARTICLE THREE. Meetings, Attendance. A. Regular Meetings. The Authority shall meet monthly and at other times as necessary. B. Special Meetings. Special Meetings of the Authority may be called by the Chair or the Vice - Chair in the absence of the Chair. C. Attendance. Attendance requirements, including provisions for removal from office for lack thereof, is governed by Ordinance No. 01-55, as amended, or by its successor ordinance. ARTICLE FOUR. Officers, Quorum, Rules of Procedure. A. Officers. At its earliest opportunity, the membership of the Authority shall elect a chairman and vice chairman from among the members. Officers shall serve for a one year term with eligibility for reelection. At the end of each term, the Chair shall prepare and submit an annual report describing the activities of the Authority. B. Filling officer vacancies. Should a vacancy occur, the membership of the Authority shall elect a replacement from among the members at the next available committee meeting? C. Quorum. The presence of a majority of the members shall constitute a quorum of the Authority necessary to take action and transact business. D. By-laws. By-laws that establish procedures for doing its work and conducting its business shall be adopted by majority vote of the entire membership, adopt as provided by county ordinances. The by-laws shall include, but not be limited to, its general procedure, funding, and expenditures. Page 2 of 3 Packet Pg. 2359 15.A.3 E. Sunshine Laws. The Authority shall operate in the Sunshine, and shall keep a written record of meetings, resolutions, findings, and determinations. Copies of all of the Authority minutes, resolutions, reports, and exhibits shall be filed with the Board of County Commissioners and or its Clerk when appropriate. ARTICLE FIVE. Work Groups A. The Authority may convene technical working groups from the community periodically to address the following: 1. Community education and awareness. 2. Emergency medical dispatch. 3. Trauma triage and care. 4. Pre -hospital emergency medical training. 5. Clinical coordination and quality outcomes. 6. Field coordination and operational concerns. B. The Authority will develop general guidelines and scope(s) of study for the technical working groups identified above. C. Membership of the technical working groups noted above may not exceed 50% participation by a member(s) of the Authority and membership on a technical working committee shall be formally recognized by the Authority before receiving a request for work or input. D. Specific guidance and charge will be given to technical working groups at regularly scheduled Public Safety Authority meetings. Such guidance shall not be in conflict with the Health Insurance Portability and Accountability Act or other laws of the State of Florida, local or state regulations, and local ordinances. E. Designation of persons filling temporary or standing committees shall be approved by the Authority and their charge clearly stated. Written reports of findings and oral presentations to the Authority will be duly recorded and submitted on behalf of the body. Page 3 of 3 Packet Pg. 2360 15.A.3 r. BL4C�YEMERGENCY AND COMMUNITY MEDICAL AUTHORITY BYLAWS ARTICLE ONE - Creation, Purpose, and Objectives The Collier County Public SafetyEmergency and Community Medical Authority (hereinafter the "Authority") was re eFeated by QFdinaRee 14 ARRn adepted by4e is an Advisory Board to the Collier County Board of County Commissioners , Board to the Beard of r,,URty GemMOSS*GReics(hereinafter the "BCC') and is tasked by the BCC with the following ebjeet+uesauthorities and responsibilities: A. To assist the BCC with issues affecting pre -hospital emergency medical services, interfacility transport services and community paramedical services (all of which are referred to herein individually and collectively as the "Services") within all of Collier County. B. To hear issues associated with „re -hospital e.,. eFgeney Mere".-,i service-S the Services when requested by the BCC, County Staff, or a participating agency, and to make written recommendations to the BeardBCC for the resolution of Missi Rvel ed agenciessuch issues. C. To work to improve and enhance pFe "^spit^' emergency medical ear^the Services within Collier County with theFeugh study, eduGatien, and system wide paFticipation by the Provided by all response agencies and the local hospital and medical community as noted aecommunities. D. To make its special knowledge and expertise available to the BCC, County Staff and any and all participating agencies upon request se . h-,Fge d duFffi g . „lar heard_ m tiRgsbv the BCC. E. To serve as a catalyst to effect cooperative arrangements for improving and best utilizing eFAeFgenr=y meth^ -a' resources in Collier County, utilizing the resources of a4the County itself, as well as municipal, dependent and independent fire organizations, 911 call centers, private transport organizations, law enforcement agencies, the media and the public. F. To make recommendations regarding the provision of Services, includin>; first responder programs, training programs, communication systems, and other appropriate facilities and services that positively impact on the delivery of emergency Medical Servie-^Sthe Carvirac G. To assist in the development of Interlocal Agreements and appropriate standards of care provided by all agencies so as to adjust levels of service commensurate with the needs of Packet Pg. 2361 15.A.3 citizens, residents and visitors of Collier County. Such efforts shall be in a cooperative fashion so as to implement those changes consistently countywide by all appropriate agencies. H. To carry out the authorities and responsibilities assigned to it from time to time by the BCC's enabling ordinance and other legislation, including to evaluate all requests for Certificates of Public Convenience and Necessity (COPCN), and make written recommendations to the BCC with respect thereto. I. To perform or assist with any other function or duty as requested by the BeaFdBCC. 4 J.To make and deliver to the BCC written reports of the majority and any minority views of the Authority's members on any issue before the EMA. ARTICLE TWO — Membership, Terms of Office, Filling Vacancies A. The Publ*c Safety —Authority will be acomposed of five me^^"^r committee with members who are residents of the County having no affiliation with any hospital, Service provider (other than Collier County itself), fire district, EMS, municipality or Collier County Sheriff's Office. B. Terms for all Authority members shall be four years. C. Filling Vacancies. When a vacancy in membership occurs, the staff liaison will ensure the vacancy is publicly noticed. Applications will be forwarded to the staff liaison to review for qualifications. The membership of the Authority shall review applications and make recommendations of appointment to the Board Of CeHRty G^mmi«ieneFs.BCC. The Authority may interview candidates at a scheduled public meeting. D. Reappointment. Members are eligible for reappointment. The staff liaison shall provide the ReadBCC with attendance records of all applicants seeking reappointment. ARTICLE THREE. Meetings, Attendance. A. Regular Meetings. The Authority shall meet monthly and at other times as necessary. B. Special Meetings. Special Meetings of the Authority may be called by the Chair or the Vice - Chair in the absence of the Chair. C. Attendance. Attendance requirements, including provisions for removal from office for lack thereof, is governed by Ordinance No. 01-55, as amended, or by its successor ordinance. ARTICLE FOUR. Officers, Quorum, Rules of Procedure. Page 2 of 4 Packet Pg. 2362 15.A.3 A. Officers. At it earliest eppeFt„nityAt the first meeting each yea r, or as soon as practicable thereafter the membership of the Authority shall elect a chairman and vice chairman from among the members. Officers shall serve for a one year term with eligibility for reelection. At the end of each term, the Chair shall prepare and submit an annual report describing the activities of the Authority. B. Filling officer vacancies. Should a vacancy occur, the membership of the Authority shall electareplaoementfromamongthemem atthe meet assoonasreasonabMxachcable. C. Quorum. The presence of a majority of the members shall constitute a quorum of the Authority necessary to take action and transact business. D. By-laws. By-laws that establish procedures for doing its work and conducting its business shall be adopted by majority vote of the entire membership, adopt as provided by county ordinances. The by-laws shall include, but not be limited to, its general procedure, funding, and expenditures. E. Sunshine Laws. The Authority shall operate in the Sunshine, and shall keep a written record of meetings, resolutions, findings, and determinations. Copies of all of the Authority minutes, resolutions, reports, and exhibits shall be filed with the Board of County Commissioners and-Zor its Clerk when appropriate. ARTICLE FIVE. Work Groups AT —The Authority may convene ica1 rkinggroupsfromthe community periodicallytoaddress the fellew+ng issue or matter within its authorities and awareness. responsibilities. 2L. A. any issue or matter within its authorities and- [F,responsibilities. 3. Emergency medieal dispatch. 4. Trauma triage and care. --_ Pre hospital eFneFlTARGY ndir_aI tram outcomes. S. Field r orrl natioR - „J eperati al -------j N B. TheAuthorityMMaydevelopgeneralguidelinesandsoope(s)ofstudyforthe iealworldnggroups tifiedebeve. C. onanalworkingeernmitteeshall beformallyrecognized bytheAuthoritybeforereceivingarequestforwork or input. D. Specificguidance and charge will be given totechn ica1 rkinggroupsatregularlyscheduledPublieSafetyAuthority meetings. Such guidance shall not be in conflict with the Health Insurance Portability and Page 3 of 4 Packet Pg. 2363 15.A.3 Accountability Act or other applicable laws of the State of Florida, 4x42p licable ordinances of Collier County or &tat-eapplicable State or County regulations, and 19eal 9FdiRaRees- E. Designation of persons filling temporary or standing committees shall be approved by the Authority and their charge clearly stated. Written reports of findings and oral presentations to the Authority will be duly recorded and submitted on behalf of the body. F. If more than one member of the Authority is serving on a working group, it shall operate in the Sunshine. Page 4 of 4 Packet Pg. 2364 15.A.3 AMBITRANS MEDICAL TRANSPORT, INC. DECEIVED JUL 1 5 2020 Collier County 2020 COPCN Renewal Application Collier County, Florida Ambitrans Medical Transport, Inc., submits its 2020 Application for Renewal of its Certificate of Public Convenience and Necessity in and for Collier County, Florida. Packet Pg. 2365 15.A.3 Ambitrans Medical Transport, Inc. - Collier County COPCN Renewal Application Sec. 50-55 Procedure for obtaining certificate. An applicant for a certificate shall obtain forms from the department to be completed and returned to the division administrator. Each application shall contain: (1) The name, age and address of the owner of the ambulance orALS provider, or if the owner is a corporation, then of the directors of the corporation and of all of the stockholders holding more than 25 percent of the outstanding shares. For governmental units, this information shall be supplied for members of the governing body. Corporate Officers/Directors Michael 1. Grant, 70, 4351 Pinnacle Street, Charlotte Harbor, FL 33980 50% Lorraine B. Grant, 65, 4351 Pinnacle Street, Charlotte Harbor, FL 33980 50% Alan J. Skavroneck, 55, 4351 Pinnacle Street, Charlotte Harbor, FL 33980 0% Vanessa Grant Oliver, 39, 4351 Pinnacle Street, Charlotte Harbor, FL 33980 0% (2) The boundaries of the territory desired to be served. Collier County, Florida (3) The number and brief description of the ambulances or other vehicles the applicant will have available. Ambitrans currently has thirty-six licensed ambulances available to its fleet. These units are permitted with the Florida Department of Health - Bureau of EMS as Advanced Life Support and Basic Life Support vehicles. Through the use of the company's computer aided dispatch software, Zoll Data RescueNet Dispatch -Billing", management is able to staff according to anticipated demand. Staffing levels and patterns are determined using historical data and other internal statistics. Vehicles are posted in accordance with direction from our communications center personnel to specified areas to aid in proper deployment and call response. In the event of increased call volume, Ambitrans has the ability to schedule additional labor and resources to meet any unforeseen increase in market demand. A spreadsheet listing each ambulance in our fleet is attached hereto as Exhibit "A." Packet Pg. 2366 15.A.3 Ambitrans Medical Transport, Inc. - Collier County COPCN Renewal Application (4) The address of the intended headquarters and any substations. Ambitrans corporate office is located at: 4351 Pinnacle Street, Port Charlotte, FL 33980 Our Collier County substation is located at: 2157 Pine Ridge Road, Naples, FL 34109 (former NCH ambulance station) Our auxiliary substation to backup the Collier County operation is located at: 935 N.E. 701 Terrace, Cape Coral, FL 33909 Packet Pg. 2367 15.A.3 Ambitrans Medical Transport, Inc. - Collier County COPCN Renewal Application (5) The training and experience of the applicant. Ambitrans Medical Transport, Inc. was incorporated in 1983 to provide Paratransit services to the residents of Charlotte County. In 1988, ownership of the company transferred to its current principals. In 1995, Ambitrans commenced its ambulance operations. Today, Ambitrans operates in Charlotte, Collier, Lee, Sarasota and Manatee counties. Ambitrans is committed to maintaining compliance with all federal, state and local laws and regulations. We are compliant with Florida Statute 401 and Florida Administrative Code 64J in accordance with standards set forth by the Bureau of EMS and Department of Health. Our state license is valid through June 19, 2021. A copy of our state license is attached hereto as Exhibit "B." Ambitrans is a licensed Medicare and Medicaid provider and we have contracts in place with many national third -party payors, which enable us to serve all citizens of Collier County. Further, we employ a national law firm specializing in Medicare issues related to the ambulance industry to ensure we remain compliant with all federal laws, rules and regulations relating to Medicare, as well as in an -house General Counsel to ensure our facility contracts and daily operations conform with all federal, state and local regulations. The management team at Ambitrans collectively has over 200 years of experience in the EMS industry. Our Training and Quality Assurance Department reviews patient care reports for quality assurance and adherence to our medical protocols and standards of care. Our education team is also responsible for our in-house training, which includes CPR, Advanced Cardiac Life Support, Pediatric Advanced Life Support, Emergency Vehicles Operators Course and on -going continuing education units needed for bi-annual certification renewal. Our in-house billing department is knowledgeable and responsive and available Monday through Friday to answer any questions our customers may have. Packet Pg. 2368 15.A.3 Ambitrans Medical Transport, Inc. - Collier County COPCN Renewal Application Our personnel and managers have diverse experiences that take them well outside of Southwest Florida. Michael Grant, our President and CEO, is the Majority Whip for the Florida House of Representatives, District 75. Our Chief Operating Officer, Alan Skavroneck, serves as the immediate Past -President for the Florida Ambulance Association and recently completed his term as State Surgeon General appointee to the Emergency Medical Services Advisory Council. Vanessa Oliver, our Chief Administrative Officer and General Counsel, is one of only 139 attorneys in the State to achieve Florida Bar Board Certification in Health Law. She is a past gubernatorial appointee to the State Board of Funeral, Cemetery and Consumer Services. Dr. Daniel V. O'Leary serves as our medical director of record as mandated under Florida Statute 401,265. This is in addition to his normal day-to-day duties as an emergency room physician at Peace River Medical Center in Port Charlotte as well as serving as the Medical Director for Charlotte County Fire and EMS. (6) The name and addresses of three Collier County residents who will act as references for the applicant. Patricia Davis 212 Napa Ridge Road East Naples, FL 34119 Representative Matt Hudson 3301 East Tamiami Trail Naples, FL 34112 Senator Garrett Richter 2320 Harrier Run Naples, FL 34105 Packet Pg. 2369 15.A.3 Ambitrans Medical Transport, Inc. - Collier County COPCN Renewal Application (7) A schedule of rates which the service intends to charge. A0428 Basic Life Support Base Rate A0429 Basic Life Support Base Rate A0426 Advanced Life Support Base Rate A0427 Advanced Life Support Base Rate A0433 Advanced Life Support Base Rate - Level 2 A0434 Specialty Care Transport Base Rate A0425 Per Loaded Mile A0999 Oxygen A0999 Drugs IV Supplies -- - -- --- -- $395.00 $425.00 — - --- --- - $395.00 $500.00 $725.00 $10.00 $45.00 $10.00 - $25.00 $20.00 - $25.00 Packet Pg. 2370 15.A.3 Ambitrans Medical Transport, Inc. - Collier County COPCN Renewal Application (S) Such other pertinent information as the administrator may require. No additional information was requested by the administrator at the time of submission However, for your convenience, Ambitrans has attached hereto a copy of its Certificate of Insurance as Exhibit "C" and its Certificate of Worker's Compensation Insurance as Exhibit T." Dr. O'Leary's DEA license and Department of Health license information is attached hereto as composite Exhibit "E." (9) An application or renewal fee of $250.00. (Exception Collier County EMS). Ambitrans' check in the amount of $250.00 is enclosed with this Renewal Application. (10) Financial data including assets and liabilities of the operator. A schedule of all debts encumbering any equipment shall be included. Ambitrans' financial data is attached hereto as Exhibit " F." Packet Pg. 2371 15.A.3 Ambitrans Medical Transport, Inc. - Collier County COPCN Renewal Application Schedule of Exhibits Exhibit "A" List of Ambulances in Fleet Exhibit "B" State License Exhibit "C" Certificate of Insurance Exhibit "D" Certificate of Worker's Compensation Insurance Exhibit "E" Medical Director Certifications Exhibit "F" Financial Data Packet Pg. 2372 15.A.3 IM Ambitrans Medical Transport, Inc. Licensed Ambulance - 2020 A B C I D 1 Vehicle Identification Number 1FDSS3ESODDA41561 1FDSS3ESODDA41561 1FDSS3ES1BDB27801 1FDSS3ES1BDB27801 1FDSS3ES3BDA26145 1FDSS3ES3BDA26145 1FDSS3ES3CDA18371 1FDSS3ES3CDA18371 1FDSS3ES4BDA26137 1FDSS3ES4BDA26137 1FDSS3ES5ADA25626 1FDSS3ES5ADA25626 1FDSS3ES5CDA18372 1FDSS3ES5CDA18372 1FDSS3ES6ADA31208 1FDSS3ES6ADA31208 1FDSS3ES6BDA26138 1FDSS3ES6BDA26138 1FDSS3ES6BDB36820 1FDSS3ES6BDB36820 1FD5S3ES7BDB27799 1FDSS3ES7BDB27799 1FDSS3ES7BDB27804 1FDSS3ES7BDB27804 1FDSS3ES8DDBO2266 1FDSS3ES8DDBO2266 1FDSS3ES9EDA22265 1FDSS3ES9EDA22265 1FDWE3FD7ADA20886 1FDWE3FS3ADA32551 1FDWE3FS3ADA32551 1FDWE3FS4ADA62447 1FDWE3FS4ADA62447 1FDWE3FS5ADA20885 1FDWE3FS5ADA20885 1FDWE3FS6BDA87027 1FDWE3FS6BDA87027 1FDWE3FS7ADA20886 1FDWE3FS7ADA69148 1FDWE3FS7ADA69148 1FDWE3FS88DA01958 1FDWE3FS88DA01958 1FDWE3FS8BDA09607 1FDWE3FS8BDA09607 1FDWE3F59ADA34661 License Type VEHICLE PERMIT (ALS) VEHICLE PERMITS (BLS) VEHICLE PERMIT (ALS) VEHICLE PERMITS (BLS) VEHICLE PERMIT (ALS) VEHICLE PERMITS (BLS) VEHICLE PERMIT (ALS) VEHICLE PERMITS (BLS) VEHICLE PERMIT (ALS) VEHICLE PERMITS (BLS) VEHICLE PERMIT (ALS) VEHICLE PERMITS (BLS) VEHICLE PERMIT (ALS) VEHICLE PERMITS (BLS) VEHICLE PERMIT (ALS) VEHICLE PERMITS (BLS) VEHICLE PERMIT (ALS) VEHICLE PERMITS (BLS) VEHICLE PERMIT (ALS) VEHICLE PERMITS (BLS) VEHICLE PERMIT (ALS) VEHICLE PERMITS (BLS) VEHICLE PERMIT (ALS) VEHICLE PERMITS (BLS) VEHICLE PERMIT (ALS) VEHICLE PERMITS (BLS) VEHICLE PERMIT (ALS) VEHICLE PERMITS (BLS) VEHICLE PERMITS (BLS) VEHICLE PERMIT (ALS) VEHICLE PERMITS (BLS) VEHICLE PERMIT (ALS) VEHICLE PERMITS (BLS) VEHICLE PERMIT (ALS) VEHICLE PERMITS (BLS) VEHICLE PERMIT (ALS) VEHICLE PERMITS (BLS) VEHICLE PERMIT (ALS) VEHICLE PERMIT (ALS) VEHICLE PERMITS (BLS) VEHICLE PERMIT (ALS) VEHICLE PERMITS (BLS) VEHICLE PERMIT (ALS) VEHICLE PERMITS (BLS) VEHICLE PERMIT (ALS) License Number 20888 4956 17027 5212 20881 4355 20885 4832 20882 4775 20879 4677 20886 4954 20880 4678 20884 4475 22521 5940 20883 4777 17026 5213 20889 4776 20890 4823 5121 20895 4822 20891 5119 20892 5120 20896 4821 20893 18535 5216 21048 5368 18896 5218 19943 Effective Date 8/24/2017 2/18/2016 12/8/2011 8/24/2017 8/24/2017 2/24/2011 8/24/2017 4/8/2015 8/24/2017 7/31/2014 8/24/2017 8/1/2013 8/24/2017 2/18/2016 8/24/2017 8/1/2013 8/24/2017 3/29/2012 10/1/2019 10/1/2019 8/24/2017 7/31/2014 12/8/2011 8/24/2017 8/24/2017 7/31/2014 8/24/2017 3/10/2015 3/8/2017 8/24/2017 3/10/2015 8/24/2017 3/8/2017 8/24/2017 3/8/2017 8/24/2017 3/10/2015 8/24/2017 7/31/2014 8/24/2017 10/25/2017 10/25/2017 3/10/2015 8/24/2017 6/6/2016 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 Exhibit "A" 1 Packet Pg. 2373 15.A.3 Ambitrans Medical Transport, Inc. Licensed Ambulance - 2020 A I B C D 47 1FDWE3FS9ADA34661 1FDWR3FSXBDA09608 1FDWR3FSXBDA09608 1FDXE4FSOEDA55897 1FDXE4FSOEDA55897 1FDXE4FSOGDC00665 1FDXE4FSOGDC00665 1FDXE4FS2BDB29932 1FDXE4FS2BDB29932 1FDXE4FS2EDA55898 1FDXE4FS2EDA55898 1FDXE4FS2GDCO0666 1FDXE4FS2GDC00666 1FDXE4FS3BDB29941 1FDXE4FS3BDB29941 1FDXE4FS3BDB35786 1FDXE4FS3BDB35786 1FDXE4FS4BDB35781 1FDXE4FS4BDB35781 1FDXE4FS6CDA90604 1FDXE4FS6CDA90604 1FDXE4FS8BDB35783 1FDXE4FS8BDB35783 1FDXE4FS8GDC04320 1FDXE4FS8GDC04320 1FDXE4FSXGDC04321 lFDXE4FSXGDC04321 VEHICLE PERMITS (BLS) VEHICLE PERMIT (ALS) VEHICLE PERMITS (BLS) VEHICLE PERMIT (ALS) VEHICLE PERMITS (BLS) VEHICLE PERMIT (ALS) VEHICLE PERMITS (BLS) VEHICLE PERMIT (ALS) VEHICLE PERMITS (BLS) VEHICLE PERMIT (ALS) VEHICLE PERMITS (BLS) VEHICLE PERMIT (ALS) VEHICLE PERMITS (BLS) VEHICLE PERMIT (ALS) VEHICLE PERMITS (BLS) VEHICLE PERMIT (ALS) VEHICLE PERMITS (BLS) VEHICLE PERMIT (ALS) VEHICLE PERMITS (BLS) VEHICLE PERMIT (ALS) VEHICLE PERMITS (BLS) VEHICLE PERMIT (ALS) VEHICLE PERMITS (BLS) VEHICLE PERMIT (ALS) VEHICLE PERMITS (BLS) VEHICLE PERMIT (ALS) VEHICLE PERMITS (BLS) 5224 19338 5219 22001 5692 22759 6007 19699 5220 22002 5693 22760 6008 19758 5222 19759 5223 19757 5221 19956 5225 19957 5226 23009 6112 23010 6113 8/24/2017 8/24/2015 8/24/2017 1/18/2019 1/18/2019 2/3/2020 2/3/2020 1/19/2016 8/24/2017 1/18/2019 1/18/2019 2/3/2020 2/3/2020 2/18/2016 8/24/2017 2/18/2016 8/24/2017 2/18/2016 8/24/2017 6/20/2016 8/24/2017 6/20/2016 8/24/2017 6/5/2020 6/5/2020 6/5/2020 6/5/2020 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 Exhibit "A" 2 Packet Pg. 2374 15.A.3 M r , STATE OF FLORIDA DEPARTMENT OF HEALTH BUREAU OF EMERGENCY MEDICAL OVERSIGHT ADVANCED LIFE SUPPORT SERVICE LICENSE This is tocertif�y that A.NIBI'1'R:1NS ..NIEI)ICAI,'IRANSPOR'1', INC. Provider Number # 804 Name of Prol ider 4351 PINNACLE STREET, PORT CHARL0'1-1-E, FLORIDA 33980 Address has complied with Chapter 401, Florida Statutes. and Chapter 04,1-I, Florida Administrative Code, and is authorized to operate as an Advanced Life Support Service subject to mty and all limitations specified in the applicable Certificate(s) 01 Public Comenience and Necessitv and/or Mutual Aid Agreements Rir the C'ourm(s) listed below: CHARLOTTE, COLLIER, LEE, MANATEE S SARASOTA COamC Isl Steve A McCov E nergenc� Medical Services Administrator Florida Department off Iealth THIS CERTIFICATE EXPIRES ON: 06/19/2021 This certificate shall be posted in the above mentioned establishment Packet Pg. 2375 Client#: 16583 GRANTMED2 15.A.3 ACORD- CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 6126/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES ZELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED EPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer any rights to the certificate holder in lieu of such endorsement(s). PRODUCER I NAMEACT Bouchard Insurance Bouchard Insurance (SAR) PHONE _ - — — -FAX [SIC No, EXt� 941 922 0245 (AIC, No): 941 923 4126 5310 Clark Road, Suite 1 ADDRESS: CLCerts@Bouchardlnsurance.com Sarasota, FL 34233 - 941 922-0245 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A : Arch Insurance Company 11150 INSURED Grant Medical Transportation, Inc. 4351 Pinnacle Street Charlotte Harbor, FL 33980 INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, --- _ -- INSR ADDL;SUBR - POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR ;WVD POLICY NUMBER MMIDDIYYYY MMIDDIYYYY LIMITS A x COMMERCIAL GENERAL LIABILITY MAPK08386904 7/01/2019 07/01/2020 EACH OCCURRENCE j 51,000,000 CLAIMS -MADE X OCCUR Professional Liab DAMAGE TO RENTED PREMISES (Ea occurrence) MED EXP (Any one person) i -- i S 100,000 X S 5,000 MAPK08386904 7101/201907/0112020PERSONAL&ADVINJURY $1,000,000 53,000,000 GEN'L X AGGREGATE LIMIT APPLIES PER POLICY ❑ JECOT —I LOC ', GENERAL AGGREGATE PRODUCTS - COMPIOPAGG `------ -- s3,000,000 S OTHER. AUTOMOBILE LIABILITY MAPK08386904 7/01/2019 'COMBINED SINGLE LIMIT 07/01/2020 (Eaaccidentl S1,000,000 $ ANY AUTO BODILY INJURY (Per person) X OWNED X SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED : AUTOS ONLY X AUTOS ONLY ! BODILY INJURY (Per accident) PROPERTY DAMAGE SPer accident)_ _- _ I S $ 7/01/2019 07/01/2020 EACH OCCURRENCE S 52 000 000 A X UMBRELLA LIAB X i OCCUR MAUM08509604 EXCESS LIAB CLAIMS -MADE ---------------� AGGREGATE _ I ---- --- $2i000,000 _ — - IE17 X RETENTION SO S WORKERS COMPENSATION IPEAR AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? NIA (Mandatory In NH) iOTH- E L. EACH ACCIDENT C---- E.L DISEASE - EA EMPLOYEE S - S If yes, describe under DESCRIPTION OF OPERATIONS below j_ _ I ''I E.L DISEASE -POLICY LIMIT 5 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) ** Supplemental Name ** First Supplemental Name applies to all policies - Grant Medical Transportation, Inc. Policy# MAPK08386904 - : Ambulance Management Services, LLC Policy# MAPK08386904 - : Ambitrans Medical Transport, Inc. (See Attached Descriptions) FL Dept. of Health, Bureau of Emergency Medical Services 4052 Bald Cypress Way MB C-18 Tallahassee, FL 32399-1738 ACORD 25 (2016/03) 1 of 2 #S1099987/M1099964 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ALIRO Packet Pg. 2376 15.A.3 Policy# MAPK08386904 - Policy# MAUM08509604 - licy# MAUM08509604 - "licv# MAUM08509604 - DESCRIPTIONS (Continued from Page 1) Venice Ambulance Service, Inc. Ambulance Management Services, LLC Ambitrans Medical Transport, Inc. Venice Ambulance Service, Inc. #S1099987/M1099964 Packet Pg. 2377 Client#: 16294 AMBITRAN 15.A.3 ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 11/07/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED `EPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. MPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer any rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Bouchard Insurance I PHONE- 941 922-0245 TFAX 941 923 4126 I (AIC No, Extjl�(AIC, No) 6310 ClarkRoad,Suite 1 !A ooRlEss: cicerts@bouchardinsurance.com Sarasota, FL 34233 - INSURER(S) AFFORDING COVERAGE I NAIC p 941 922-0245 INSURER A: Continental Divide Insurance Company 35939 INSURED INSURER B , Ambitrans Medical Transport, Inc. — — - - - -- - — — — 4351 Pinnacle Street INSURER C : �' INSURER D Punta Gorda, FL 33980 INSURER E INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL;SUBR _-- POLICY EFF POLICYEXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MMIDD/YYYY MMIDDIYYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S CLAIMS -MADE OCCUR C DAMAGE T 1 RENTED PREMISES Ea occurrence S S_. MED EXP(Any, one person) PERSONAL & ADV INJURY S S GEN'L AGGREGATE LIMIT APPLIES PER ' GENERAL AGGREGATE ��j PRO- POLICY I JECT LOC PRODUCTS - COMP/OP AGG $ S OTHER. AUTOMOBILE _ LIABILITY COMBINED SINGLE LIMIT (Ea accident) 5 S ANY AUTO', BODILY INJURY (Per person) _. OWNED SCHEDULED AUTOS ONLY AUTOS ...._ BODILY INJURY (Per accident) S _S HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE SPeraccidenll UMBRELLA LIAB OCCUR EACH OCCURRENCE is EXCESS LIAB ICLAIMS-MADE AGGREGATE ttt DED RETENTION 5 S A WORKERS COMPENSATION AMWCi034477 AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y I N 12/27/2019 12/27/2026,, X ,.PER OTH- STATUTE ER E.L EACH ACCIDENT $1 000,000 OFFICERIMEMBER EXCLUDED? � NIA -4 $1,000,000 (Mandatory In NH) E.L. DISEASE - EA EMPLOYEE _ S1 ,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below EL DISEASE - POLICY LIMIT I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CE For Informational Purposes Only For Informational Purposes Only SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) 1 of 1 The ACORD name and logo are registered marks of ACORD #S1200926/M1200920 ALEFA Packet Pg. 2378 15.A.3 DEA REGISTRATION THIS REGISTRATION NUMBER EXPIRES FEE PAID 00441218 12-31-2021 $731 SCHEDULES BUSINESSACTIVITY ISSUE DATE 2,2N, PRACTITIONER 11-07-2018 DANI MBITRANS MEDICAL TRANSPORT 351 PINNACLE ST PORT CHARLOTTE, FL 33980-2902 REPORT CHANGES cif N PROMPTLY t]€ 3 LL CONTROLLED SUBSTANCE/REGULATED CHEMICAL REGISTRATION CERTIFICATE UNITED STATES DEPARTMENT OF JUSTICE DRUG ENFORCEMENT ADMINISTRATION WASHINGTON D.C. 20537 Sections 304 and 1008 (21 USC 824 and 958) of the Controlled Substances Act of 1970, as amended, provide that the Attorney General may revoke or suspend a registration to manufacture, distribute, dispense, import or export a controlled substance. THIS CERTIFICATE IS NOT TRANSFERABLE ON CHANGE OF OWNERSHIP, CONTROL, LOCATION, OR BUSINESS ACTIVITY, AND IT IS NOT VALID AFTER THE EXPIRATION DATE. REQUESTING MODIFICATIONS TO YOUR REGISTRATION CERTIFICATE To request a change to your registered name, address, the drug schedule or the drug codes you handle, please 1. visit our web site at deadlverslon.usdoj.gov - or 2 call our customer Service Center at 1-(800) 882.9539 - or 3. submit your change(s) In writing to: Drug Enforcement Administration P.O. Box 2639 Springfield, VA 22152.2639 See Title 21 Code of Federal Regulations, Section 1301.51 for complete instructions. _______ You have been registered to handle the following chemical/drug codes_______ Packet Pg. 2379 15.A.3 This page has been left blank intentionally. Packet Pg. 2380 15.A.3 BRIAN W. CROSLAND, CPA, PL CERTIFIED PUBLIC ACCOUNTING & CONSULTING 201 W. MARION AVENUE, SUITE 1204 PONTA GORDA, F1,33950 PHONE: 941.629.1197 FA('SINil LF: 941.2115.5279 KRISTI L. SCOTT A%IERI(-AN INti 1141 1'F OF (*ERI IFIEI) Pt RLII" ACCO( NTANTS FLOW D,A INiTITL FE OF CERMILD Pt ULIC' ACCOUNTANTS SH.AWN NI. COOLEY, CPA %IEDI(:AL GROUP NIA\AGEftFST ASSOCIATION C(ININIUNIT) ASSOCIATIONS INSTITUTE INDEPENDENT ACCOUNTANTS' COMPILATION REPORT To the Board of Directors Ambitrans Medical Transport, Inc. Charlotte Harbor, Florida We have compiled the accompanying statement of assets and liabilities of the ambulance transportation operations of Ambitrans Medical Transport, Inc. and subsidiaries as of April 30, 2020. This financial statement has been prepared on the income basis of accounting utilized by the Company for federal income tax reporting purposes. We have not audited or reviewed the accompanying financial statement and, accordingly, do not express an opinion or provide any assurance about whether the financial statement is in accordance with the income tax basis of accounting. Management is responsible for the preparation and fair presentation of the financial statement in accordance with the income tax basis of accounting and for designing, implementing, and maintaining internal control relevant to the preparation and fair presentation of the financial statement. Our responsibility is to conduct the compilation in accordance with Statements on Standards for Accounting and Review Services issued by the American Institute of Certified Public Accountants. The �. objective of a compilation is to assist management in presenting financial information in the form of a financial statement without undertaking to obtain or provide any assurance that there are no material modifications that should be made to the financial statement. The accompanying statement was prepared for the purpose of presenting the assets and liabilities of the ambulance transportation operations of Ambitrans Medical Transport, Inc. and subsidiaries, and is not intended to be a complete presentation of Ambitrans Medical Transport, Inc. and subsidiaries consolidated assets and liabilities. Accordingly, this report and related financial statement is restricted for use only by known third parties with knowledge of these restrictions and should not be used for any other purpose. (/ 'G(.�C.1L/ June 25, 2020 Punta Gorda, Florida EXCELLENCE SINCE 1984 Packet Pg. 2381 15.A.3 Ambitrans Medical Transport, Inc. and Subsidiaries Statement of Assets and Liabilities of the Ambulance Transportation Operations Income Tax Basis of Accounting �- April 30, 2020 (Unaudited) Assets Current Assets: Cash available for ambulance transportation operations $ 695,000 Property and Eauipment Office equipment and computers 165,909 Machinery and equipment 822,713 Medical transportation vehicles 1,743,486 2,732,108 Less accumulated depreciation (2,667,709) Property and Equipment, net 64,399 Total Assets $ 759,399 Liabilities Current Liabilities: Accrued profit sharing $ 194,121 Other liabilities 37,500 Notes payable to banks 313,186 544,807 Long Term Liabilities: Notes payable to banks 195,000 Less current portion above (195,000) Total liabilities 544,807 Net Assets Over Liabilities, income tax basis $ 214,592 Read Independent Accountants' Compilation Report Packet Pg. 2382 15.A.3 MediCab rans oration DBA - Medicab Advantage, LLC Duns# 0/4491489 1 Cage# /X1X0 Table of Contents Introduction & Purpose letter by Martin Ndung'u — President ...........I ................... Current Collier County Demographic census ..........................................................................3-6 Basic Life Support (BLS) Oxygen Therapy...................................................................................7 BLSOxygen order........................................................................8 MediCab Director Agreement & MD's license copies.............................................................9-11 Copyof Transfer Sheet.................................................................................................................12 .................................................................... Physician Certification Statement • . . • . . • • • • • . . . • •""""""" 1' FL -EMS Ambulance BLS Service License Requirements......................................................14-18 FL -EMS Ambulance BLS service medical equipment and supplies.......................................19-21 FL -DOH BLS vehicle inspection log .................. .........................................................................22 Certificate of Current General Liability Insurance (MediCab Transportation LLC) ...................23 Certificate of Current Commercial Auto Insurance (MediCab Transportation LLC) ..................24 Current Certificate for Workers Compensation ............................... ......•••••.............•.•••..•...••••••.•••25 FL -DOH persormel form...............................................................................................................26 FL -DOH service records and facilities inspccti()n........................................................................27 OurProposed Rates.......................................................................................................................28 OurCapability Statement..............................................................................................................29 Martin Ndung' u, President — Resume ..........................30 Packet Pg. 2383 15.A.3 MediCab rans ort67bon DBA - Medicab Advantage, LLC Duns# 0/4491489 1 Cage# iX1XO May 151", 2020 MediCab Transportation LLC 13240 North Cleveland Ave suite 44, North Fort Myers FL 33903. Collier County Board of Commissioners Re: Basic Life Support Service (BLS) Collier County. Collier County Board of Commissioners kindly consider our application for a COPCN in Collier County. MediCab Transportation LLC would like to apply for a BLS license. We would like to provide interfacility transfers in Collier County according to Florida statute 401.23 part 7, 8 and Florida 401.25 part 1 For patients who require oxygen during transportation which is a higher level of transport requiring a licensed healthcare professional to be in a BLS ambulance. We would like to incorporate this additional service in lieu of EMT's as per Florida statutes 401.23 part 7 and 8. MediCab Transportation LLC has been operational since 2013 and has been serving in Lee and Collier Counties. We have partnered with Hospitals and rehab facilities in Collier County. We are contracted by David Lawrence Center, The Willoughs of Naples, Physicians Regional Hospital and Landmark Hospital, among others. We have on our team. Dr. Kenneth Berdick as our Medical Director. Our executive team has over 86 years of combined medical experience. Our major partners include Lee Healthcare Systems, Promise Hospital, Lehigh Acres Hospital, Park Royal Hospital, and a myriad of rehab facilities. We look forward to your support and facilitation to provide BLS services for all Collier County residents. r Sincerely, Martin Ndungu President. Packet Pg. 2 4 15.A.3 fir` +sir raps ports ion DBA - Medicab Ad vantage, LLC Duns# 0/4491489 1 Cage# /X1X0 Collier County COPCN application as required by FL -DOH for initial Licensure as an EMS/BLS provider July 24, 2020 Packet Pg. 2385 15.A.3 MediCab rans ortation DBA - Medicab Advantaqe, LLC Duns# 074491489 1 Cage# /X1X0 According to the Collier County Board website, Collier County population grew by 3.22% from 378,488 in 2018 to 390774 in 2020 for an average 6143 nem, residents per year consecutively at a growth rate of 1.60% in 2019. Southwest Florida is experiencing a rapid population growth fueled by mostly migration. Projections for population growth are on an upward scale hence most public resources are working aggressively to accommodate the needs of the crowing, population is Collier County. We see an opportunity to step in and help already existing infrastructure with the expanding need for oxygen bound patients using Basic Life support (BLS) ambulance. Medicab Transportation LLC has a team of ambulance certified drivers and certified EMT's to help with BLS transportation for oxygen bound patients especially if they are experiencing acute distress such as increased pain, difficulty in breathing or restlessness as per Florida statute 401.23 part 8. Herein, find enclosed reports with all required Florida State documents, Martin Ndung'u resume President Medicab Transportation LLC, our BLS rate- sheet and current insurance certificates. Director and Board members please feel free to contact me at 239.980.3900 or 239.479.1444 incase you have any questions or comments, you can also email me martini i?nnedicabirwis.coiii- 1 want to thank you for reviewing our application. 1 am grateful for your time and consideration Sincerely, Martin Ndungu — President. Packet Pg. 2386 World Population Review 15.A.3 Collier County, Florida Population 2020 2020 Growth Rate 1 F)W/ Collier County, Florida's estimated population is 390,774 with a growth rate of 1.60%a in the past year according to the most der ent United Stdtes census data. Collier County, Florida is Use 17th largest County Website Collier County County in Florida. State Flori a Year Population Growth Growth Rate Founded May 8, 1923 2020 39U,774 6,143 1,601 County Seat East N R!as Lat/Lng (26-20, -81.000) 2019 384,631 6.143 1.62% 2018 378,488 6,143 1.65%, 2017 372,345 7,000 1.92% 2016 365,345 9,238 2.59 /" 2015 356,107 8,781 2,53 %. 2014 347,326 8,261 2.44`%v 2013 339,065 6,788 2.04% 2012 332.277 4,645 1.42% 2011 327,632 5,037 1.56% 2010 322,595 170.496 112,10% 1990 152,099 66,128 76.92% 1980 85,971 47,931 126.00% 1970 38.040 22,287 141.48% 1960 15,753 9,265 142.80% 1950 6.468 1,386 27.17% 1940 5,102 2.219 76.97% 1930 2,883 0.00% Collier County, Florida Population Growth Packet Pg. 2387 15.A.3 Collier County, Florida Population by Race Source: US Census 2010 601-Year Survav_(Table 803002) Population by Race lA Hispanic Non -Hispanic Race Population . Percentage White 320,642 88.11% Black or African American 25.356 6.97% Some Other Race 7,707 2,12% Two or More Races 4,676 1.28% Asian 4,508 1.24% American Indian and Alaska Native 1,012 0.28% Native Hawaiian and Other Pacific Islander 21 0.01% White Bl.uk or AGmw Am¢tllcan Amenran Indhn and Alaska nalive Mom Nahvo Hnw:iiian and Other PanO[ 16IR110101 Some Olbrr Race Two o, More Rac" Collier County, Florida Population by Age Source; US Census 2018 ACS 5-Year Survcy_(Table 50U1) Collier County, Florida Population Pyramid 2020 OQ -- 75 1() 65 60 55 50 45 40 35 �0 25 K 5 0 8K dK 0 0 Male AK 3K 6K ElF emale Collier County, Florida Median Age 50.3 48.5 51.8 Total Male Female Collier County, Florida Adults There are 299.554 adults, (112.279 of whom are seniors) in Collier County, Florida. Collier County, Florida Age Dependency 94.3 Age Dependency Ratio 0 60 Old Age Dependency Ratio 8 34.4 Child Dependency Ratio A Collier County, Florida Sex Ratio Female 184,586 50,72% Male 179,336 49.28% 2/13 Packet Pg. 2388 15.A.3 Projections of Florida Population by County, 2020-2045, with Estimates for 2016 County Estimates Projections, April 1 and State April 1, 2016 2020 2025 2030 2035 2040 2045 ALACHUA Low 257,062 252,800 252,500 252,100 250,800 248,900 246,400 Medium 265,500 278,000 275,200 295,400 283,100 312,100 290,300 328,900 296,700 345,700 302,700 362,700 High Sw 26,965 26,200 26,000 25,800 25,400 25,000 24,S00 Low Low Medium 27,800 29,400 28,700 31,300 29,500 33,200 30,100 35,000 30,600 36,800 31,100 38,500 High BAY 176,016 173,800 175,300 176,200 175,600 174,000 172,100 Low Medium 184,700 194,900 194,600 211,304 202,700 227,200 209,400 242,300 215,100 257,100 220,700 272,600 High BRADFORD 27,440 27,200 26,600 25,900 25,200 24,400 23,700 Low Medium 28,800 30,500 29,300 32,000 29,500 33,300 29,700 34,600 29,900 35,900 30,100 37,200 High BREVARD 568,919 572,500 583,500 592,900 596,300 597,700 598,200 Low Medium 595,700 616,900 625,500 661,800 649,200 704,000 666,300 741,200 681,700 777,800 696,100 815,101) High BROWARD 1,854,513 1,865,100 1,901,700 1,933,400 1,952,400 1,962,300 1,969,800 Low Medium 1,940,700 2,038,400 2,156,800 2,117,200 2,295,600 2,182,300 2,426,900 2,237,900 2,553,700 2,290,800 2,684,000 High 2,010,100 CALHOUN 14,580 14,000 13,800 13,500 13,200 12,800 12,500 Low Medium 14,900 15,700 15,200 16,600 15,400 17,400 15,600 18,100 15,700 18,900 15,900 19,600 High CHARLOTTE 170,450 169,300 171,900 174,000 174,700 174,400 173,400 Low Medium 180,100 190,000 191,000 207,300 200,400 224,300 208,400 241,000 215,600 257,700 222,100 274,700 High CITRUS 143,054 141,300 142,000 142,700 142,500 141,500 140,000 Low Medium 148,400 155,300 154,500 166,000 159,600 176,400 163,800 186,300 167,100 195,700 170,000 204,900 High CLAY 205,321 209,500 218,700 226,400 232,300 236,900 240,100 Low Medium 223,400 244,200 262,100 278,700 294,100 308,300 High 235,000 263,600 291,800 320,500 350,100 380,400 COLUiR Low 350,202 359,600 376,600 391,500 404,300 414,600 42-2,400 Medium 379,200 413,000 442,000 469,200 493,800 516,000 High 395,400 440,S00 484,800 530,100 575,900 621,900 COLUMBIA Low 68,566 67,700 67,800 67,800 67,500 66,900 66,000 Medium 71,100 73,700 75,800 77,600 79,100 80,300 High 74,500 79,300 83,900 88,300 92,600 96,600 DESOTO Low 35,141 34,200 33,800 33,600 33,200 32,700 32,200 Medium 35,900 36,700 37,500 38,200 38,700 39,200 High 37,600 39,500 41,500 43,400 45,300 47,200 DIXIE Low 16,773 16,200 16,000 15,800 15,600 15,200 14,900 Medium 17,200 17,700 16,100 18,400 18,700 16,900 High 18,200 19,300 20,400 21,400 22,400 23,400 Bureau of Economics and Business Research, Florida Population Stuides, Bulletin 177 5 Packet Pg. 2389 15.A.3 MediCab rarlsportation DBA - Medicab Advantaqe, LLC Duns# 0/4491489 1 Cage# JX1X0 Basic Life Support (BLS) Oxygen Order During Transport Oxygen therapy orders must be transported via BLS or ALS ambulance vehicles. According Florida regulation 61N-1.027 Distribution of Medical Oxygen for Emergency Use. Also, according to the FDA, oxygen is a medication and must be treated as such. Like most prescription medications oxygen must be administered carefully. It is ordered by a doctor to meet a patient prescribed respiratory needs and must be administered by certified EMT's, paramedics or nurses while on transport. Packet Pg. 2390 15.A.3 MediCab ranspartatian DBA - Medicab Advantage, LLC Duns# 074491489 1 Cage# 7X1X0 MediCab Transportation LLC Medical Director agreement As per our attestation agreement our Medical director's participation, review, and approval, Dr. Kenneth Berdick, MD I agree to act as the Medical Director for MediCab Transportation LLC ambulance Basic Life Support (BLS) services. Signature of Medical Director Approval Date M.D/D.O. # Packet Pg. 2391 15.A.3 AC# 9 $ 5 4 5- STATE OF FLORIDA DEPARTMENT OF HEALTH DIVISION OF MEDICAL QUALITY ASSURANCE DATE LICENSE NO. CONTROL NO. 12/1812018 ME 17772 643463 The MEDICAL DOCTOR named below has met all requirements of the laws and rules of the state of Florida. Expiration Date: JANUARY 31, 2021 KENNETH A BERDICK, MD 3714 EVANS AVE FORT MYERS, FL 33901 QUALIFICATION(S): DISPENSING PRACTITIONER w o z D Z J Z U N n > z a m o = N O Q < z ELL = O J U W Q 2 j J m Y o „ Q U olLo U m o of Lfl WOW O I-2 w o Cam JL 2 Q 1 Z W wo ,„ I- .i N m <g, S 2.0 O IL-0 a Wa w - �a o Z Q d 5 m E v W N O O P E Y iA O Rick Scott Celeste M7Philip, M.D., M.P.H. GOVERNOR Surgeon General and Secretary j c a DISPLAY IF REQUIRED BY LAW 'o a EXPIRATION DATE: JANUARY 31, 2021 Your license number is ME 17772. Please use it in all correspondence with your board/council. Each licensee is solely responsible for notifying the Department in writing of the licensee's current mailing address and practice location address. If you have not received your renewal notice 90 days prior to the expiration date shown on this license, please visit www.FLHealLhSource.govand click "Renew A Licens to renew online. Medical Quality Assurance has a new and improved Online Services Portal. In the new system, you have the abilityto renew your license, update your mailing and practice location addresses, request name change, request duplicate license and update your profile information all from the convenience of your online account. I. Go to www.FLHealthSource.gov. 2. Click on "Provider Services" and select -Manage Your License." 3. Select your profession and license type and click "Submit" 4. The question "Have you Renewed or Applied Online Since 2015?" will display. a. Click on "No" if you have not registered for an account in the new system and follow the instructions provided for new user registration. b. Click on "Yes" if you are a returning user. Enter the user ID and password you selected during the registration process, then select "Sign In" to access your MQAOnline Services Portal account. IMPORTANT ANNOUNCEMENTS Are You Renewal Ready Grounds for Discipline The Department of Health will now review your continuing education records atthe time of license renewal. To learn more, please visit www FLHealthSource.9ov1AYRR You should be familiar with the Grounds for Discipline found in Section 456.072(1), Florida Statutes, and in the practice act for the profession in which you are licensed. Florida Statutes can be accessed at www.leg.state.n.us/Statutes v M CO) Packet Pg. 2392 15.A.3 a 0 N Cl) 0 E LL BERDICK, KENNETH A MD 3714 EVANS AVE FORT MYERS, FL 33901-0000 IllilIII-1111(111111r 1ilnrlilil1111ditlu(1rIII ,IIII'd 11tllli FEE PAID $731 ISSUE DATE 07-30-2018 CONTROLLED SUBSTANCE REGISTRATION CERTIFICATE UNITED STATES DEPARTMENT OF JUSTICE DRUG ENFORCEMENT ADMINISTRATION WASHINGTON D.C. 20537 Sections 304 and 1008 (21 USC 824 and 958) of the Controlled Substances Act of 1970, as amended, provide that the Attorney General may revoke or suspend a registration 10 manufacture, distribute, dispense, import or export a controlled substance. THIS CERTIFICATE IS NOT TRANSFERABLE ON CHANGE OF OWNERSHIP, CONTROL, LOCATION, OR BUSINESS ACTIVITY, AND IT IS NOT VALID AFTER THE EXPIRATION DATE. CONTROLLED SUBSTANCE REGISTRATION CERTIFICATE UNITED STATES DEPARTMENT OF JUSTICE DRUG ENFORCEMENT ADMINISTRATION WASHINGTON D.C. 20537 DEA REGISTRATION THIS REGISTRATION FEE NUMBER EXPIRES PAID AB 1006988 07-31-2021 $731 SCHEDULES BUSINESS ACTIVITY ISSUE DATE 2,2N, PRACTITIONER 07-30-2018 3,3N,4,5 E W Gt a BERDICK, KENNETH A MD Sections 304 and 1008 (21 USC 824 and 958) of the 3714 EVANS AVE Controlled Substances Act of 1970, as amended, FORT MYERS, FL 33901-0000 provide that the Attorney General may revoke or suspend a registration to manufacture, distribute, dispense, import or export a controlled substance. THIS CERTIFICATE IS NOT TRANSFERABLE ON CHANGE OF OWNERSHIP, CONTROL, LOCATION, OR BUSINESS AC AND IT IS NOT VALID AFTER THE EXPIRATION DATE. Packet Pg. 2393 15.A.3 MediCab rans portation DBA - Medicab Advantaqe, LLC duns# 0/449148-P I Cagett /Y1X0 BASIC LIFE SUPPORT (BLS) INTERFACILITY TRANSFER FORM Form to be populated on all BLS inter facility transfers for all patient discharged or transferred via non -emergency Basic Life Support. SECT A: Transportation company Name & title of caller and facility calling for transport Names of BLS transport team Patient Name: Mode of transportation: Discharging facility and Rm # Pickup Time: Destination address: Discharging facility phone # _ Destination address: DOB &MR #: Is patient DNR: YES , NO Ext If patient is DNR, Florida Yellow State form MUST be provided with essential discharging paperwork upon discharge and transport of patient. If DNR is not provided patient is deemed full code during transport. Transferring Nurse/Clinician: RECEIVING FACILITY Nurse/Clinician accepting the patient: Date/Time: Date/Time: Packet Pg. 2394 15.A.3 13240 North Cleveland Avenue #4 - North Fort Flyers, FL 33903 w . ..e _ 479-1444 . Fax 1 (877) 745-8863 spear titi n (239 ) ®BA -- Medicaias9 j#c g�tagie, LLC Run # Physician Certification Statement SECTION I —GENERAL INFORMATION Patient's Name: Date of Birth: Medicare #: Transport Date: .4 (PCs is only valid for the transport date.) Origin: Destination: Is the patient's status considered as inpatient in the hospital's admission record at the time of transport? ❑YES ❑ NO Closest appropriate facility? ❑ YES ❑ NO—ip Why is transport to more distant facility required? if hospital -to-hospital transfer, describe services needed at 2,d facility not available at 11 facility: If hospice patient, is this transport related to patient's terminal illness? ❑ N/A ❑ NO ❑ YES--►Condition: ..................................................................................................................>, SECTION If —MEDICAL -NECESSITY QUESTIONNAIRE Ambulance Transportation is medically necessary only if other means of transportation are contraindicated or would be potentially harmful to the patient To meet this requirement, the patient must suffer from a condition such that transport by means other than an ambulance is contraindicatec by the patient's condition. The following questions require an answer in order for this form to be valid: 1) is this patient "bed confined" as defined below? ❑YES ❑ NO To be "bed confined" the patient must satisfy all three of the following conditions: (1)unable to get up from bed without assistance; 6Nh_0 (21 unable to ambulate without assistance; AND (3) unable to sit in a chair or wheelchair 2) Can this patient be safely seated and transported by car or wheelchair vehicle without a medical ❑ YES ❑ NO attendant monitoring the patient? 3) In addition to completing questions 1-2 above, please check any of the following conditions that apply`: ('Note: supporting documentation for any boxes checked must be maintained in the patient's medical records.) ❑ Advanced airway management r Cardiac or hemodynamic monitoring ❑ required enroute ❑ iV Solutions (Medicated) ❑ IV Solutions (Non -Medicated) ORequires oxygen —unable to self-administer, maintain and regulate ❑ Danger to self/others 0 Need or possible need for restraints 0 Patient is combative, Agitated o Accelerated neurological disorders requiring medical monitoring Z ❑Patient suffers from AMS, ALOC, or Alzheimer's/Dementia 0 other (specify): ❑ Condition requires elevation of a lower e..ctremity ❑ Contractures ❑ Fractures (Non -healed) ❑ Fractures requiring 90- rule OPatient in moderate/severe pain orthopedic device (backboard, halo, 0/--� pins, traction, brace, wed e, etc) re- V gmring special handling monitoring dduring transport o 0 Paralysis ❑ Paraplegia ❑ Hemiplegia O Quadriplegia Am utntlons_ Location BKA AKA BEA AEA Right ❑ 0 ❑ O Left O ❑ O O ❑ Medical attendant required E ❑Patient monitoring post pain management/sedation O ❑ Patient is unresponsive i 8 O Postoperative surgical monitoring ❑ Pain medications required ❑ seizure precautions Isolation/infection control precautions z° requiring special handling Morb�d obesity requires additional ❑ persp nel/equipment to safely handle patient-wweight lbs. Unable to sit in a chair or wheelchair to ❑due to wounds or decubitus ulcers. Circle Stage Level: 11I IV End :............................ SECTION IiI SIGNATURE F� PHYSICIAN OR HEALTHCARE PROFESSIONAL i certify that the above information is true and correct based on my evaluation of this patient, and represent that the patient requires transport by ambulance and that other forms of transport are contraindicated. 1 understand that this information will be used by the Centers for Medicare and Medicaid Services (CMS) to support the determination of medical necessity for ambulance services, and I represent that I have personal knowledge of the patient's condition at the time of transport Signature of Physician or Healthcare Professional Date Signed Printed Name and Credentials of Physician or Healthcare Professional (MD, DO, RN, Discharge Planner) If unable to obtain the signature of the attending physician, any of the following may sign (please check appropriate box below): 0 Physician Assistant ❑ Nurse Practitioner ❑ Clinical Nurse Specialist ❑ Discharge Planner ❑ Registered Nurse Packet Pg. 2395 2111o019 Statutes &c*nmoxwunMew Statutes: Online Sunshine Select Year: 2018 v iGo 7�� ^^`~��°Florida Statutes PUBLIC HEALTH MEDICAL TELECOMMUNICATIONS AND TRANSPORTATION 401'252 foterfaci0tytransfer. — (1) A Licensed basic or advanced Life support ambulance service may conduct irterfadUty transfers in a permitted ambulance, using a registered nurse in o(acecf an emergency medical technician or paramedic, if: (a) The registered nurse holds e current certificate ofsuccessful cmursccornpiehon in advanced cardiac life support; (b) The ohydcianincharge has granted pern/issionfor such atransfe� h has the veimfsen4ce required for'such transfer, and has deemed the patient to be in such a condition appropriate to this type of ambulance staffing; and (c) The registered nurse operates within the scope of part | of chapter464. (I) AUcenned basic or advanced life support service may conduct interfaciUtytransfers in a permitted ambulance ifthe patient's treating physician certifies that the transfer isnnedicaUyappropriate and the physician provides reasonable transfer orders. An inLerfaciUty transfer must be conducted in a permitted ambulance if it is determined that the patient needs, or is likely to need, medical attention during transport, If the emergency medical technician or paramedic believes the level of patient care required during the transfer 1nbeyond his orher capability, the medical director, orhis nrher designee, must be contacted for clearance prior tmconducting the transfer. If necessary, the medical director, or his orher designee, shall attempt to contact the treating physician for consultation to determine the appropriateness ofthe transfer. (3) Infants less than 28days old qrinfants weighing less than 5 kilograms, who require critical care interfac1iity transport boa neonatal intensive care unit' shall be transported in a permitted advanced life support or basic life support transport ambulance, or in 8 permitted advanced Life support or basic Life support ambulance that is recognized by the department asmeeting designated criteria for neonatal inberfacihtycritical care transport. History.—o.r. 25' ch. 82'402; s. 13.rh. 83-196; ss. 6. 36.ch. 92'78; s, 7*2.ch. 95'148;s,*4. ch. 97'257; s. 1U8' ch. 2008'318; s. 16, opyright 01995 2019The Florida Legislature ^ ^ Contact. Ls ��woo�^e�o�o�x�o�mn�n�o xxn,xm"��g,s�� /.z5^ 2M11209 Statutes aConstitution �iewStatutes: Online Sunshine Select Year: 2018 T Go �� * ^/=��~,��uv^��Sta1utes Title XMX PUBLIC HEALTH MEDICAL TELECOMMUNICATIONS AND TRANSPORTATION 401.26 Vehicle permits for basic life support and advanced life support services. - (1) Every licensee shall possess a valid permit for each transport vehicle, advanced life support nontransport vehicle, and aircraft in use. Applications for such permits xhai( be made upon forms prescribed by the department. The licensee shalt provide documentation that each vehicle for which a permit is sought meets the appropriate requirements for a basic life support oradvanced life support service vehicle, whichever is applicable, as specified by rule of the department. Apprm|t is not required for an advanced life support nuntransporivehicle that is intended to be used for scene supervision, incident command, orthe augmentation ofuuppUes. (2) Tbreceive a valid permit, the applicant must submit a completed apphcation form for each vehicle or aircraft for which a permit is desired, pay the appropriate fees established as provided in s. 401.34, and provide documentation that each vehicle oraircraft meets the fo(|o°ing requirements as established by rule of the department; the vehicle oraircraft must: (a) Be furnished with essentiat medical supplies and equipment which is in good working order. (b) Meet appropriate standards for design and construction, (c) Reequipped with anappropriate communicabonsymtem' (d) Meet appropriate safety standards. (e) Meet sanitation and maintenance standards. (/) Be insured for an appropriate sum against injuries to or the death of any person arising out of an accident. (]) The department may deny, suspend, orrevoke a permit ifitdetermines that the vehicle, aircraft, or equipment fails to meet the requirements specified in this part urinthe rules o/the department. (4) A permit issued in accordance with this section will expire automatically concurrent with the service license. (5) In order to renew *vehicie or aircraft permit issued pursuant to this part, the applicant must: (a) Submit a renewal application. Such application must be received by the department not more than 90dmys orless than 3Odays prior bmthe expiration ofthepernit. (b) Submit the appropriate fee or fees, established as provided in s. 401.34. (c) Provide documentation that current standards for issuance of a permit are met. (6) The department shall establish criteria and time (imits, for substitution of permitted vehicles that are out of service for maintenance purposes. (7) The department shall adopt and enforce rules necessary toadminister this section. h 7yZoO o 2 ] ch Ot xiswry , � ch 7}�2o' s ] cx 76'mm; o�I5u.ch.77'147;s. 1.ch. 77-��7�s� 1y.�x. 7x9x�o� /. �u.c � � . . . . � - ' ' -^ '] ' 8] 1Y$' � 5� ch V3 o�0' � n c� &*']17� � 58 ch. 86'220: o. 7. 36, ch. 92'7$-s. 19. ch. 98' ]18;o, 9.74'ls.ch. ��oz�s� � .cn. . . . � ' , , . ,- . ,o. �M14&1 �Q ooxwo�oummmnwn*o xn,�x°*w^��a�m��u�o�m�sxm�, ~�~..~,.-._ --'- hit in a New Day In Public Neofth. 15.A.3 The Florida Depanman or Health worry to protect. promote & mp erve the health of air people in Honda through Integrated state, County, & community efforts, lit. ..- HEALTH () Search About Us (httpJ/www.ftorkiaheat h4w/about4wdeWnmentof•healttt/about•uslndex.htmi) I Contact Us (httpsNwa•on-contactus- prd.aiurewebsltes.neln I Newsroom (httpt//www.Mnridaheaithgoy/newsrvomAndex.htmi) Programs & Services Licensing & Regulation Statistics & Data Certificates Diseases & Conditions Environmental Health (/programsand- (fllcensing-and• (/statistics -and- (/cenifkateslndex.htr4Miseases-and- (/environmental. stwkes/index.htmli regulatlonirindexhtmll dataAndexhtml) conditlonsnndexlitml) health/Index.html) CD N O EMS Sa vks Pm ldar � linme l / /I x. mn » 1 ke�nQ aft nDn t nnrfnY hrml) p EMS Service Provider Licensing N °,�,lt,il=nd' EMS Service Provider Licensing N Tranaa Tr port ►raaeed Contact the Florida Department wreatrino+nd $encV Medical Sendces (/ /nrovider ond-partner• of Health At-- tesl=PS/adv!sory-rnttnrlls ctAkeholder-gr� rntmcliAndex.html) J 4W (� Q fia F].tWhaalengov imtllro EMS* Llcensure of EMS Providers FAQ nhealm goyl Y ftre�aer P BL2AS-4P$ ALS k S MO. rpaJ�raavloa• Floridaor.o.aan� of Health3 +a �„(d,r..e,i.uon+rtd 1. Who needs a BLS or ALS ambulance service license? 4052 Bald Cypress war Bin A- Q pp�Inaa+rc�JNnl) Pursuant to rules 401.25, 64j-1,002, 64j-1.003, Florida T2aa.h+is<., Administrative Code, every person, firm, corporation, association or F< fC DNS corttreAlkAlicen governmental entity owning or acting as an agent for the owner of V Nlmnshga,a rapW.aortlwn.+avto.- any business or service, which furnishes, operates, conducts, a,a maintains, advertises, engages in, proposes to engage In or worwr+earrw^ �Wwldnreeernb:ra) professes to engage in the business or service of providing pre- hospital Interfaclliry advanced life support services or basic life � V or earo PrVVWM i" as'"d support transportation service, must be licensed as a basic or C W �v N^ba advanced life support ambulance service, before offering such wow service to the public. L d aorttdlare.h- p„vhw.ttar) 2. What are the requirements for a BLS or AU ambulance E service license? The requirements are listed on the application for BLS or ALS LLl ambulance licensure. The following is a partial list of the major � requirements: Certificate of Public Convenience and Necessity M from the county commission in the county you wish to CO) (COPCN) operate your service, a medical director (licensed Florida physician) with a Department of justice -Drug Enforcement Administration CD IDEA) registration (DEA registration is required for ALS only), vehlde transport and an approved N CD liability insurance, trauma protocols radio communication system. Approval of a radio communication N system Is completed by Department of Management Services N (DMSFlnformadon Technology Program. Contact DMS for more +' information on EMS radio communication systems. to 3 3. What is the required staffing for BLS and ALS vehcles and air IM 3 ambulances? Pursuant to section 401.25(7Xa), Florida Statutes, BLS vehicles are Q required to have, at a minimum, an emergency medical technician (EMI) attending the patient and a driver meeting the requirements d Y in section 401.281, Florida Statutes. v M Pursuant to section 401.25(7Xb), Florida Statutes, ALS vehicles are 1 L required to have, at a minimum, a paramedic attending the patient M and an EMT. C Pursuant to section 401.252, Florida Statutes, Inter4acility ambulance staffing is based on the patients condition as Q determined by the medical director. Q Aircraft-prehospital air ambulances are required to have, at a W minimum, one paramedic. Air Ambulance C d 1. Who needs an air ambulance service license? L Pursuant to section 401.281, Florida Statutes, and rule 64j-1,005, v Florida Administrative Code, every person, firm, corporation, tQ association or governmental entity owning or acting as an agent for 4.1 the owner of any business or service, which furnishes, operates, conducts, maintains, advertises, engages in, proposes to engage in to engage in the business or service of transporting by or professes air ambulance, must be licensed as an air ambulance service, before offering such service to the public. 2. What are the requirements for an air ambulance service Iicense7 The requirements are listed on the application for AIR ambulance licensure. The following is a partial list of the major requirement Certificate of Public Convenience and Necessity (COPCN) from the county commission In the county you wish to operate your director (licensed Florida physician) prehospital service, a medical with a Department of Justice -Drug Enforcement Administration /4 (DEA)registration (p spory)• liabilityPacket Pg. 2398 21' htl insurance, trauma transport protocols and an approved radio communication systern 15.A.3 communication system, Approval of a radio is completed by DMS-Division of Telecommunication. Contact DMS for more information on EMS radio communication systems. Driver and personnel Requirements 1, What are the requirements for an ambulance driver? An ambulance driver must meet the following requirements: • is at least 18 years of age; • certifies under oath that he or she is not addicted to alcohol or any controlled substance, and is free from any physical or mental defect or disease that might impair their ability to drive an ambulance; • upon initial designation as a driver, has not within the past three years, been convicted of driving under the influence of alcohol or controlled substance and has not had a driver's N license suspended under the point system provided for In G Chapter 322, Florida Statutes; N • successfully completed a 16 hour course of instruction on N driving an authorized emergency vehicle, which includes, at a minimum, classroom and behind the wheel training, 13t1}e.b9k N 1.013• � r �= Admininrative Code 3 (hrtns'/A ••^•, flruiec oral�va-tewa-..KLSuteNo.aso2 �ical%2oService &iD=64)1,013)for t) 3 title=Eme gcng details on the 16 hour course content; a valid American Red Cross or National Safety Council Q • possess first aid course or its equtvalenG and :t • possess a valid American Red Cross or American Heart C Association cardiopulmonary resuscitation card. t Reference jeC1LQnAQLW, Florida Statutes 3 Q fl' c c ^t t �rindex cfrri� (hup:11 w.lee ,Ysrts gpn mode -Display SIB *g4 S'^rch String &t1R1=0400_ 04991n t0j SertianVjjQ .Z1.htmlj and R ,U 64i•1.M Floridr V gdfninicrrath Code thttncl/wwv+firules oreleatgYdaylRuieNo a<a' � title=EmerQ P �OMed' ^I%204n cec&10}-1.0131• Laws 0 to Emergency Medical What are the law and rules governing CD CD Services? 1. Chap�terA0l.Fiorida S atr't s E (http;/Awrw.leg s"'^ a uslAatutecrndex cfm'? LU 6922-,mode=Dlspid catutaWRL=0 00- j /()dt11 COn[enLlndex_htmb 0eeemnn 2. fi4}-1 Adminlstradv ode n/1v:rn.flrules.org/oa_t�waYfiL°rHome.asp� � M CO) Fees G N what are the fees for ambulance service licensure? e N Pursuant to Section 401.34, Florida Statutes, the fees are 5660.00 N for a BLS license and 51,375.00 for an ALS and Air license, plus $25.00 for each vehicle or aircraft you permit under your license. }, N The license and vehicle permits are issued for two years. 3 If I want to change the status of my license from BLS to ALS 171 3 during my two-year cycle will you pro -rate the fees? Q NO, the fees will not be pro -rated. You would be considered a new , service, charged the full fee, and the license will be good for two ++ d years from the date of issue of your ALS license _11C v inspections M d 1. is an inspection from your department required as part of to the ficensure application process? NO, an inspection of your vehicles and service records and facilities C y Is not required prior to licensure. However, your service will receive an Inspection within 90 days of your licensure issuance date. Q Service Changes W 1, What happens if my service decides to move? A license is valid only for the service location for which it was another application, and the fee d originally issued, you must submit E is $30.00. Reference se ion 401 321,1JJnrida 5taWtf1 V i`itp ((i�c/ctatutecllndeX Cftrt? car aPszt_arch String=&URL 0400- oem�n�K nipnclQA01 ??1 htmf#04LL1 3211 It is the responsibility of the Ilcensed provider to keep current the records on file in the EMS Section. During the two-year licensure (such as the medical director's period, documentation may expire contract, medical director's physician license, DEA registration, vehide/aircraft liability insurance, and COPCN). The provider should automatically submit current Information in a timely fashion. other Transport Service - No Jurisdiction 1.1 want to operate a wheelchair and stretcher transport office license these services also? service, Does your NO, we do not license non -ambulatory passenger taxi services, as they do not provide medical transport. A service of this type is transport to non -ambulatory passengers not in need or r providing likely to need medical attention, if a service of this type provides packet pg. 2399 transport to a passenger that is in need of or likely to need medical attention they are in violation of Chapter 401, Florida Statutes and must be licensed as an ambulance service. Some Honda counties do regulate wheelchair and stretcher services. Call the county commission office of the county in which you desire to operate this type of service for information, Vehicle Permits FAQ 1. Do I need to have vehicle or aircraft permitted before operating them? Yes, vehicles and aircraft must be permitted under your service license before operating them. Florida AdminLglative Code (https•//wmy flruies orgigatewav/RUIeNo.aW title--F ameaz O%ZQ edica % 0 rvice 541_1,51{iZ). 2- what are the levels of vehicle permitting? Vehicles are permitted either at the BLS or ALS level. Once permitted at that level, the vehicle must be operated at all times at that level with the required staffing and equipment. Reference section 401.26, Florida statutes. 3. 1 have a permitted vehidelaircraft that requires maintenance. Can I use an unpermitted vehide/aircraft in its place? Yes, when It is necessary for a permitted vehicie/alrcraft to be out of service for routine maintenance or repairs, a substitute vehicle/aircraft meeting the same transport capabilities and equipment specifications as the out of service vehide/aircraft may be used for a period of time not to exceed 30 days. An unpermltted vehide/aircraft 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 licensee and shall be accessible to the department: • identification of permitted vehide/a)rcraft taken out of service; • identification of substitute vehiclelaircraft; and, • the date on which the substitute veh(cielaircraft was placed Into service, the date on which it was removed from service and the date the permitted vehide/aircraft was returned to service. 4. If i permit a vehicle/aircraft In the middle of my two-year Ilcensure cycle, hove long is the permit good for? The permit WILL expire at the same time your license does. (UAUaIdUanspoEtnrotocoLhtml)some of the files on this page may require Adobe Acrobat- Download a free version of the Ado Acrobat Reader (hStp;Ug"t adobe cam/reader!). Last Modifled Date: Feb 9, 2017 9:21:32 AM Last Reviewed Date: Feb 9, 2017 9:21:32 AM FFATURFD PROGRWS Florida Health Across the State Surgeon General and Secretary ;'' ei hi (http:ltwww,noridaheahh.gav/about-the-depanment- i. uut-uslssg/tndex.Mrn)) t ship .a...�,^-�.(htiPJ%vww.fkrkdaheakh.govtsbouc-thrdeWnment= (/ of-heslthtabouc-ustkadershcpnndnchtml} °.Flortd•�',..$- County Health Deparunerx Leadership s- (hrryrthwH+.fladdheahh ders audWexdrrnl) mt- g�kJdatbu[-ustchd-4e;darstiWivxlc�c.hrmi) (�p�/lv„�•r� crib~crofreefiortda c Boards, Councils & Committees (httpJMtww.floridahealth.gov/provider- and-partner-resources/advisory-countiis- stakeholder-groups/i ndex, htrrtl) Connect with DOH About Florida Health (http://wv. w.flori dahealth,gov/about-the- department-of-healttVabout-usl'index.html) Atiredrcadorr Uabout-the-departrt+ent-of- hea)dtrabout-uslaurtditatioN)nti•.x..html) Careers (httpJrwww.florkiahealth.gov/about-the- departmem-of-heaith:about-usJw rre+s/fndex. htmp Public Meeting tJoi)tes (Mtp�A•�a+w.fbridaheakhgov/a6otrt-the-departmerx- ot-heahhlatwut us�sunshksi Infol�bitc-meetlng- not lndex.hfrnr Public Notices (httpllwww.fl.ridaheafth.grnlabout- the-depa rtment-o(-heatthfabout-usiwnshl ru- in(o/pub)ia-noticesAnde•, html) public Retords Requem (Mmpitwww. tloridaheahh.govlabo ut-the-depanment- of-heakhraban-usrsumhine-infolpubik-records- requesmAndexht"l State Heakh knprovcment Man (faisout-the- deparimem-of•heakhlabout- vstate-and- community-health-assexsmerxlship- process/index.htmp 2019-2019 Florida Department of Health Annual Regulatory Pian (! documantV2018-2019-fdoh- anfwai-r egulatory-p! an.pdq 201 &2019 Boards' Annual Regulatory Plans V documents/201R-2019-boards-annual-regulatary- Plaix.pdf) 15.A.3 E W M CO) CD N CD N N rn 3 IM 3 G� a Certificates (httpJ/www.floridahealthlov/index.html) Birth CertRkates (httpaw*w,w.ftfWhe&".govltertWR eslcertificates%othltndew hint) Death Certificates (h"PVAv rw,nortdaheakhgovlrntWmatrstterofintes/deathAndex-html) Divorce CertiYCstm (h[tp:/twww.11artdaheaith-govlcerttfrca2sttert�RcatesldWrxcehndex.hued) rle htl I Packet Pg. 2400 2/11/208 Statutes & Constitution :View Statutes : Online Sunshine Select Year: 2018 Y / Go � Thei8 Florida Statutes Titte PUBLIC HEALTH MEDICAL TELECOMMUNICATIONS AND TRAN8pOPT«TION 401.281 Drivery.— (1) Each licensee is responsible for assuring that its vehicles are driven only by trained, experienced, and otherwise qualified personneL The licensee must, at a minimum, document that each of its drivers: (a) |uatleast 1Byears ofage; (b) Certifies under oath that he or she is not addicted to atcohot or any controtted substance; (c) Certifies under oath that heorshe is free from any physica< or mental defect or disease that might impair his orher ability todrive an ambulance; (d) Upon initial designation as a driver, has not, within the past 3years, been convicted ofdriving under the influence of a(cohot or controlled substances and has not had a driver license suspended under the point system provided for inchapter 32Z; (e) Possesses avalid driver license issued under chapter 32I, is trained inthe safe operation ofemergency vehicles, and has completed an emergency vehicle operator's course or the reasonable equivatent as approved by the department; however, this paragraph applies only to a driver of a land vehicle; (f) Possesses a vaLid American Red Cross or National Safety Council standard first aid course card or its eqcUvaien[;and (g) Possesses a vatic! American Red Cross or American Heart Association cardiopulmonary resuscitation card. (2) The department shalt periodically inspect licensees for verification ofcompliance with this section. Services that are unable to verify compliance are subject to disciplinary action as provided in this part. History.—ss. 1/' 25. c». 82'402�ss.8. ^a.ch. 83'196: :. 10.ch. 8+317; x. 60,ch. 86'I20; s. 56.cx. 89-282;o. 10. 36.ch 9I'78;s.796. ICopyright o 1PV5-20M4The Florida Legislature ~ ^ LaD1�� m�o��m�� »uv�^"p*��g.n�� __--~ --_ 15.A.3 64J-1.002 Basic Life Support Service License - Ground. (1) To obtain a license or renewal each applicant shall submit an application to the department on DH Form 631, 04/09, Ground Ambulance Service Provider License Application. This form is incorporated by reference and is available from the department, as defined by subsection 64J-1.00](9), F.A.C., or at http://www.fl-eins.com, (2) The department shall issue a license to any applicant who: (a) Furnished evidence of insurance coverage for claims arising out of injury or death of persons and damage to the property of others resulting from any cause for which the owner of said business or service would be liable. Each motor vehicle shall be insured for the sum of at least $100,000.00 for injuries to or death of any one person arising out of any one accident; the sum of at least $300,000.00 for injuries to or death of more than one person in any one accident; and, for the sum of at least $50,000.00 for damage to property arising from any one accident. Government operated service vehicles shall be insured for the sum of at least $100,000.00 for any claim or judgment and the sum of $200,000.00 total for all claims or judgments arising out of the same occurrence. Every insurance policy or contract for such insurance shall provide for the payment and satisfaction of any financial judgment entered against the operator and present insured, or any person driving the insured vehicle. All such insurance policies shall provide for 30- day cancellation notice to the department. (b) Obtained a Certificate of Public Convenience and Necessity (COPCN). (3) Each BLS provider shall ensure and document in its employee records that each of its EMTs and paramedics hold a current certification from the department. (4) Every provider, except those exempted in paragraph 64J-1.006(1)(a), F.A.C., shall ensure that each EMS vehicle permitted by the department, when available for call, shall be equipped and maintained as approved by the medical director of the service in the vehicle minimuequipment list. The vehicle minimum equipment list shall include, at a minimum, one each of the items listed m in Table I and shall be provided to the department upon request TABLE I GROUND VEHICLE BLS MEDICAL EQUIPMENT AND SUPPLIES QTY. ITEM 1. Bandaging, dressing, and taping supplies: a. Adhesive, silk, or plastic tape — assorted sizes. b, Sterile 4 x 4 inch gauze pads. c. Triangular bandages. d. Roller gauze. e. ABD (minimum 5 x 9 inch) pads. 2. Bandage shears. 3. Patient restraints, wrist and ankle. 4. Blood pressure cuffs: infant, pediatric, and adult. S. Stethoscopes: pediatric and adult. 6. Blankets. 7. Sheets (not required for non -transport vehicle.) 8. pillows with waterproof covers and pillow cases or disposable single use pillows {not required for non -transport vehicle). 9. Disposable blanket or patient rain cover. 10. Long spine board and three straps or equivalent. 1 l . Short spine board and two straps or equivalent. 12. Adult and Pediatric cervical immobilization devices (CID), approved by the medical director of the service. 13. Padding for lateral lower spine immobilization of pediatric patients or equivalent. 14. Portable oxygen tanks. "D" or "E" cylinders, with one regulator and gauge. Each tank must have a minimum pressure of 1000 psi, and liter now at 15 liters per minute. 15. Transparent oxygen masks; adult, child and infant sizes, with tubing. 16. Sets of pediatric and adult nasal cannulae with tubing. Packet Pg. 2402 15.A.3 17, Nand operated bag -valve mask resuscitators, adult and pediatric accumulator, including adult, child and infant transparent masks capable 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 GSA in KKK -A 1822E specifications. 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 IS pm 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.1. Z87.1 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, Ralemaking Authority 381,0011, 395.405, 401.121, 401.25, 401,35 FS. Law Implemented 381,0011, 395,401, 395.4015, 395,402, 395.4025, 395.403, 395.404, 395,4045, 401.23, 401.24, 401.25, 401.252, 401,26, 401.27, 401,281, 401,30, 401.31, 401.321. 401.34, 401.35, 401.41. 401.411, 401.414, 401.421 IS. Hfstory--New 11-29-82. Amended 4-26-84, 3-11-85. Formerly IOD-66.49, Amended 4-12-88. 8-3-88. 12-10-92, 10-2-94, 1- 26-97, Formerly IOD-66.049, Amended 8-4-98, 1-3-99, 11-19-01, 12-18-K Formerly 64E 2.002, Amended 9-2-09. Packet Pg. 2403 - - STATE OF FLORIDA 15.A.3 HEALTH - EMERGENCY MEDICAL SERV►_ ..t Dr..ARTMENT OF BASIC LIFE SUPPORT VEHICLE INSPECTION REPORT (SECTION 401.31, F.S.) Inspection Date: / / Phone: Service Name: Type of Inspection: ❑Initial ❑ Reinspection ❑ Random ❑ Complaint ❑Announced ❑ Unannounced County: Vehicle Information: ❑Transport ❑Non -Transport Unit# Year/Make Permit Type Permit# VIN Tag# Rating Categories: Inspection Codes: inspection 1 = Lifesaving cquipmem medical supplies, drugs records or procedures I = Item meets criteria. 2 = lntermedinte support equipment, medical supplies, drugs. records or procedures I a = item corrected during inspection to meet erileria 2 - Items not in compliance with inspection criteria. 3 = Minimal support equipment, medical supplies, records or procedures am¢ T/PARA/DRIVER TIFICATE NUMBER Crew credentlals: Section 401.27(1) 401.281, F.S. O 1And Minimum = One EMI' and One Driver N O N N Roller gauze to VEHICLE REQUIREMENTS (Stations 316 and 401, F.S., Chapter 60-1, F.A.C. and -A-1822 ABD (minimum Sx9 incti) pads 7 0) I. Exhaust System . One pair of Bandage Shcars 0 2. - Exterior Lights: . One act each, patient restraints - wrist and ankle Q ,� an A. Head lights(high t d low beam) 4. . one each blood pressure cuffs: infant, peal and adult. ' � = 'L B. Turn signals . One stethoscope: pediatric lout adult O C Broke Lights . Blankets t D. Tail Lights . Shecu. (not required on non -transport vehicles) +' 3 E. Back-up lights and audible waning device Pillows with waterproof covers and pillowcases or disposable single use pillows. (Not required on non- Q 3. Hom Tart vehicles.) . One disposable blanket or patient rain cover. V A. Windshield wipers � 10. One long spine board and three straps or equivalent. 5. Tires 11. One short spine board and two straps or equivalent, 4) G. Vehicle r- of oust and dents 7. Two-way radio communication -radio reel 12 One each adult a cervical immg and mad dev ila (CID), approved Fry the medical director to This approwl must be in writing and made available by the provider for the dcpartmcw to f the service . pprovulmu virus. 13. Set of padding for lateral lower spine imnobili�ation of pediatric patients or tquivalent, 14. Two portable oxygen tanks, "D" or "E cylinders with one regulator and gauge, Each lank must have 4) d A. Hospital (cab and patient compartment) B. Dispatch Cutter minimum ressure of l(100 . i. l5. Each transparent oxygen flasks; adult child and infant sins with tubing 16. Set of pedintric and adult nasal commine with tubing 17. one each hand operated bag -valve mask resuscitators, adult and pediatric accumulator, including dult, child and infant trans raft masks capable ruscwiihsupplcnwntalux l8. One portable suction, electric or gas powered with wide bore tubing and tips, which moo[ the um standards as published b the GSA in KKK11-1822. ci6cariorrs LU M C. Other EMS units R. Emargency Lights 9. Siren IO. Two ABC fire extinguishers fully charged and inspected in bnubets. Minimum Ills each. N 19. Assorted sizes of extremity immobilization devices. 0.One lower extremity traction splint. (Pediatric and Adult) 11. burs open properly, Clare securely. I.Orte sterile ebstetrit:al kit m inclde, el minimum bulb syringe, sterile scissors o[ scalpel and cons lamps or cord -ties. 12. Rear and side view trdrrurs_ O N 13. Wbudows sod windshield L TRANSPORT V ERICLE REQUIREMENTS lScetion 401, F S ,and CMpty 64J-1, Bum sheets. N T .A.C. and KICKA-1822) 1. Primary stretcher and three straps. One flashlight with batterirs. 4. occlusive dressings. +'' to 7 2. Auxiliarystretcher and two straps. 3. Two ceiling mounted IV holders. Assorted sizes of ompharyngeal airways. Pediatric and Adult f� G. Ono installed Oxygenwith re nor a ad wrench. minimum "M" sin cylinder. (Other instaUal gal IauB liquid oxygen, us allowed by medical dimetnc This rgiproval must be in t) 7 Q r 4. Two no -smoking signs. '` xygen delivery systems, such as r ritin and available to the department for review ) 7. Sufficient of gloves -suitable to provide barnci protcciall from btohazards for all craw 4) Y 5.Ovcthoxrl grab rail, quantity embers. O 6. Squad bench and three sets of seat bells. 8. Sufficient quantity of rack for all aewmembors - Face Masks -both surgical and respiratory d 7. Interior lights, tective, O 8. Exterior floodlights. 9. l oadi li is. 9. Assorted pediatric and adult Sias rigid cervical collars as approved u writing by the medical director 10. Heat and air conditioning with fan. available for review by the depatincrit. 11. Wart! ''And -sides, back and mirror image front.0. Nasopharyngeal airways, French or mm equivalents (iof ng .pediatric .end adult ter 643 1, F A C, anal IflQC-A-ISZZ 1. One approved biohnzardous waste plastic bag or impervious container per Chapter ow-1, TESTING (Chap device fa ui matt selection and dru dose C d Q W MEDICAL EQUIPMENT FOR 1 a Pediatric length basal meosuzument 1. Installed suction. (Transport ooly) Items 4. 14, 17. 18 and 20 in section B must be ttxted EQUIPMENT (Chapter 64J 1, F.A.C., GSA KKK -A- es or uivalmt meeting A.N.S TZ87.1 standard 2.One per crewmember, safety gogg► eq 3.One bulb syru,Ile smote from obstetrical kit 4) E V. MEDICAL SUPPLIES AND 1822 I . Bandaging dressing and unpin& supplies: , Rolls adhesive, silk or plastic tape. One thermal absorbent reflective blaarl 5. Two multi-haume dressings. _ ENERAI. SANITATION (Section 401.26(2)(e)6 F.S. t V tC Q Sterile gauze pads, any size Triangular bandage ---- Vehicle and Contents ❑ Satisfactory ❑ Unsatisfactory - Comments; tive, UPPIlcable and nt dmintsttrurive actin le defiis inspection ciencies within the atablisbed time Games winsubjectthine servicreports d is authorized representatives t(toApplicable)' representdive of the hilore tot or a correctcopy om aware of the deficiencies (If any) and understand that as outlined in Section 401, F.S, and Chapter 64J-1, F.A.C. Copy of Inspection report and Corrective Actloo Statement Received by: penalties Date' Tenon in Charge: Date- Inspected By: Packet Pg. 24 4 15.A.3 GENERAL GHANGE ENDORSEMENJ ACA-99-07 This Endorsement changes the terms and conditions of the Policy issued. Please read it carefully! Subject to all of the terms and conditions of the Policy, unless expressly changed hereby, this Endorsement and any attached Endorsement(s) are to be deemed to be and form ea part of the following Policy: PC20050545 Insured: Medicab Transportation, LLC Insurer: Prime Property & Casualty Insurance Inc. At its agency located in Sandy, Utah Endorsement Efft:rtive date 5/22/2020 Mountain Standard Time Endorsement type date: 5/26/2020 The undersigned hereby represents, acknowledges, and agrees that the Policy is amended through the inclusion of this Endorsement, and any attached Endorsements), as follows: • Physical address has been modified to: 13240 NORTH CLEVELANU AVE UNIT # 4, North Fort Myers, FL 33903 from: 13249 N Cleveland Ave., North Fort Myers, FL 33903 Total Premium: $0.00 All other terms and conditions of the policy remain unchanged. Endorsement: 2 Authorized Signature Page r or r ACA-99-07 12NOV2017_ Packet Pg. 2405 DATE ( 15.A.3 CERTIFICATE OF INSURANCE 05/1 ,RODUCER AND THE NAMED INSURED THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY Evolution Insurance Brokers, L.LC• AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE OF INSURANCE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND, OR ALTER THE COVERAGE AFFORDED 8722 S, Harrison St. BY THE INSURANCE POLICIES BELOW. Sandy. (IT 84070 INSURERS AFFORDING COVERAGE (801) 304 5�00 VSURED INSURER A Prime Property & Casualty Insurance Inc. Medic ab Transportation, LLC INSURER E Prime Insurance Company INSURER C INSURER D 1 13249 N Cleveland Ave. North FortMyers , FL 33903 "IAMITS SHOWN ARETHOSE' IN EFFECT AS OF POLICY INCEPTION" OVERAGES The policies of insurance listed below have been issued to the insured named above for the policy indicated. Notwithstanding any requirement, term or condifidn of any contract or described herein is subject to all the terms, exclusions and other document with respect to which this certificate may be issued or may pertain, the insurance afforded by the policies conditions of such policies. Aggregate limits shown may have been reduced by paid claims TYPE OF INSURANCE POLICY EFFECTIVE POLICY EXPIRATION LIMITS POLICY NUMBER DATE (MMIDDIYY) DA IF 0INVOUlYYI J Commercial Liabilitv IBl SC20050566 5/8/2020 5/8/2021 $100,000 Per Person $300,000 Per Accident J Claims Made $1,000,000 Policy Aggregate J Include Products J Include Completed Operations y Commercial Auto Liability (Al PC20050545 5/8/2020 5/8/2021 $100,000 Per Person $300,000 Per Accident Any Auto $24,000 Physical Damage -total scheduled va All Owned Autos S50,000 Property Damage J Scheduled Autos $10,000 U,M. Per Person $20,000 U.M. Per Accident Hired Autos Non -Owned Autos $10,000 PJ.P Per Person Drive Away Specifically Described Autos Commercial Garaae Liability G.K.L.L. O.T.R.P.D. D.O.C. Cargo On Hook Employee Dishonesty Wrongful Repossession Claims Made Exclude Products Exclude Completed Operations Excess Liabilitv Claims Made OTHER DESCRIPTION OF OPERATIONILOCATIONSIVEHICLESIEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS J CERTIFICATE HOLDER ADDITIONAL INSURED LOSS PAYEE BE BOARD F THE ABOVE DESCRIBED POLICIES CELLED BEFORE H OF COMMISSIONERS LTG COUNTY SHOULD ANYEXPIRATION OTE ISSUING INSURER WILL ENDEAVOR TO MAIL THEREOF, THE CERTIFICATE HOLDER NAMED TO THE LEFT, BL DAYS WRITTEN NOTICE TO THE FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND 120 Main SL UPON THE INSURER. ITS AGENTS OR REPRESENTATIVES: Fort Myers, FL 33901 AUTHORIZED REPRESENTfME Packet Pg. 2406 I 15.A.3 I SAC '®CERTIFICATEF LIABILITY INSURANCE I 12123/2099 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endolsement(s). CONTACT Susan Taylor PRODUCER NAME: PHONE (3861252-9601 aC No : (386) 239-5 i Brown & Brown of Florida. Inc, c No Ext P.O. Box 2412 ADDRESS: staylor@bbdaytona.com C Daytona Beach FL 32115-2412 INSURERA: Insurance Company of the West INSURED INSURER B : MEDICAB TRANSPORTATION, LLC INSURER C : 13240 CLEVELAND AVE #4 INSURER D : INSURER E: NORTH FORT MYERS FL 33903 INSURER F COVERAGES CERTIFICATE NUMBER: 19/20 WC REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. __ P{N. _Y EFF P011CYEXP LIMITS TYPE OF INSURANCE COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR GEN1 AGGREGATE LIMIT APPLIES PER. POLICY ❑ JECT LOC 7 AUTOMOBILE LIABILITY ANY AUTO OWNED AUTOS ONLY SCHEDULED AUTOS HIRED H NON -OWNED AUTOS ONLY AUTOS ONLY UMBRELLA LIARR I f OCCUR EXCESS LIAB '�--jl CLAIMS WORKERS COMPENSATION AND EMPLOYERS' LtABILF Y Y I N ANY PROPRIE rORIPARTNERIEXECLMVE —NJ N 1 A A 1OFFICER/MEMBEREXCLUDED? EXP S COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per Person) S BODILY INJURY (Peraccident) $ PROPERTY DAMAGE y WFL505266600 12/27(2019 112/27/2020 r_ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) PROOF OF COVERAGE 500,000 I N N r N _ a'I _ 3 EI O t 3 EI R V N SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BI THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WRH THE POLICY PROVISIONS. MEDICAB TRANSPORTATION, LLC DBA MEDICAB ADVANTAGE AUTHORIZED REPRESENTATIVE 3049 CLEVELAND AVENUE FORT MYERS FL 33901 @ 1988-2015 ACORD CORPORATION. All right., ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD Packet Pg. 2407 IMEME®®®®®®®E®®®®®® . Rr. 15.A.3 y CD �- CD n (7 Co. O z N N 1I3 10 N O CD O 0 N CD , ® m ®s ffi. m K��A P. m. W 0 < 0—m m Rid z �G ® O C r w m Co m Cr CD � O < CD C7 p m� m -± CD (D 0 c tD C: i'C 4 j5!-lil 3- z C 3 Cr eD O "CI CD M 7v CD CD CD 5 Co M ' I i m Z e 0 e `n � Z � > CD � ' `9 e M e C C C 3 M C o 0 C C s � � e 7m m I Y ` r � I I I Cm5 � Ee, 1 irs i Packet Pg. 2408 15.A.3 STATE OF FLORIDA DEPARTMENT OF HEALTH - EMERGENCY MEDICAL SERVICES SERVICE RECORDS AND FACILITIES INSPECTION REPORT (SECTION 40131, F.S.) Service Name: Inspection Date: / / Phone: (,1 County: Type of inspction-. O initial O Reinspecfioa O Random O Complaint OAnnounced O Unannounced License Type: ❑ `Fraosport O Noutrauspart Dote of Last Inspection: / / License Expiration Date: 1 / Inspection Codes: Rating Categories: I = Lifesaving equipment, medical supplies, drugs, records or procedures I = item meets inspection criteria. I a = item corrected daring inspection to next criteria. 2 = Intermediate support equipment, medical supplies, drugs, records or procedures 2 = hours not in compliance with inspection criteria. 3 = Minimal support equipment, medical supplies, records or procedures .-. 0 N 1. ADMINISTRATIVE AND RECORDS STORAGE (Chapter 643 1, F.A.C.) N 1. Records storage and security. 4. Items are stored in a climate controlled (I e - bested sad sir conditioned) loatlen. N L Records storage for 5 years. - +' U. RECORDS (Section 40t, F S Chapter64J-f, F.A.C) 1 The area is dean and sanitary. --- Current service license on display. (Chapter 64J-1, F.A.C') B. Observe if the following requ)remenh for controlled substances are being out,t. 7 2. VeblcWAtrcraR Records (Chapter 64i-1, F.A.C.) To Include: et.- t. The requirement% listed to items 105 above arc being met. -- Medical director has registered storage areas with DEA (Chapter 64J-1, F:A.C.) Q A. Registration.2. C. Written operating procedures for the storage all handling of fluids and medications sptdfy the I B. Veritladoa *(vehicle permit teflowi = 3. Previous Iuspecdan Fortes, (Chapter 64JA. •1, F.A.C.) 1. Security procedures 2. loins stored in a climate controlled location (t.t. - Heated sad air conditioned) L O t 4. Perwaod Records for each EMT, paramedic (Chapter 643•I, F.A.C.) r+ 3 To Iadadt: _ 3. Deteriorated m expired kerns stored In a gtmmndne area separate from usable items A. Daft of employment. i_.—. 1--inventory 4. Inv procedttres. B. Record of training. D. Written operating procedures for the storage and handing of controlled substances specify the R V C. Current professional certification ---_ d L Docttmeatntioa of tomPktiom of t 1488 D O.T. Air Medical Crew 1. Storage procedures. jD. National Standard Curriculum-Advaneed. for Paramedic Crew raembM _ - 1 Cho er ti4J-1 F.A.C.) 5. Ambulance driver record tfor each per Section 401.281(1), F.S.) 2. The positions that have access to controlled substances. V C To Wade.• Statements sttcs4K en A.B.C. 3. Shift change Inventory prattdures for vehicles. tU A.19 years old. __--- 4. Proeednrca to tx used for the documentation of use, disposal of excess and resupply of d B Net addicted to alcohol or controlled substances. vsldeies with cootrdled substances. _. E C. Fret Rom Physical or mental defect or disease that would. Impair 5. Procedures used for inventory discrepancies W ability to drive: F. Verity that the following ocean with regard is tartrdkd substances: . . le ➢ t)rlv[og record vetifleadoc 1. Storage records art r alWalned oo Ile at the location where be co ntr^olled substances art !r Paeness void Hats "D^ or ehasRear license. stored. _ M M F. is trainal Us safe trperaden of coos genry vet - 16 tout E V.O.C. s AB regnkvd inventories and words are maintsined at least two years. v -.G. Possesses a valid American Red Cross rh Aid mad Ptusomd 3. Records are maintained separately from dab" records. O Said card or Its uivalcni g, went artbsfitntlons xhto aatborixadea by medical dixeetor (Chapter 64.1-1, F-A.C.) EgmP H. possesses a valid Amerlean Red Cross or Americas Heart O N ores CStctton 381.ga. F S. and Ctapttrs b4J 1, F A C.) to 9nllude: Waste operating pu'ectyl N Association CPR or ACU card Current EMT or terdflcatioa is tvkkuta of tosal'"ace with NOTE: paramedic Itcrro A B C and G stove a 49127 4 F.S.) Proper T 6. Medical Director (Section 64J-1, F.A.C.) _ -.... fn A. Qualiflations: Current ACt.S certification or beard cerdficstioa to & Proper storage 7 cos rg ie^tee tChaitter 64J 1 F.A.C.)---- h_ Duties and rtspuns1tn7ttle$ (Chapter 64J-1, F.A.C.) b7) £. Prnpar d 7 Q I 1. WritthLRitw aperag procedures for patient tare ----- I& EMS providers disaster plan integrates haft total and regional disaster plan (Chapter 641-1, � operating printed arts elect sire the F.A.C. ) It. Adak and pediatric CID approval in writing by medical director (Chapter 64J-1. F.A.C.) 19 2. Wrtttea guilty assurance progam following: V 12. If an VMS provider maintains an air ambulance license or has permitted aircraft, the M a. Prompt review of run repots. following record rdrements that a Section 401.251 F.S and Chapter tr3J-1 F.A.C.)d A Emerrocy protocol for overdue aircraft, when radio communications cannot be establ(ated, b Direct oinervadoa of pereonae4 or when aircraft cannot be located. & Docuentntadoa of done 15 adontes while erratte to amd from 's location. 4) 3 Documentation atlsopteattatatba ed d2 echoic. 4, Docstateaced of ppllelpanost in cared contraet ridd I&M C. Satedy committee to Include: � Q Providers lor a ■ lishu m of 19-hours per Year ---- 1. Membership of one per, am AW medical crew member, usedles) director, EQ Q representative and one hospital administrator if b 2 7. Inventory, storage sad se-4ty Procedures for atedlcations, fluids and tonndkd L Written safety procedures. W substances Seerioms 499 893. F.S., and Chapters 64J-i, F.A.G. and tliebr are betag aloe 3. Meetings helddnrea natrsual occurrences, satiny quarterlyate o re ie safety politics, pt'ocedm' +-' A. Observe tf the following requirements for medications issuses, and eons tU 4. Safety audit resells commnnitsted to an program persenaet. E 1. Storage area is secured by a hocking mechanism. Minutes of meetings recorded sod retained on Sk for 2 yeas. Z All Item are inventoried at leatu monthly.S. � 3 Deteriorated or expired its= arc $torso hi a gnaru mtw sew, separate from usable Comments: the undersigned representative of the above service. acknowledge receipt of a copy of this Inspection narrative, applicable supplemental inspection reports and corrective actlon I.gn pre n S cknowledgncies listed (if any) and understand. that failure to correct the deficiencies within the establ'lshed fume frames Will statement (if dic� addition, I ens eve of the to administrative action and penaltles as outlined In Section 401, F.S., and Chapter 64J-1, F.A.C. Cagy of hIspersion report subject the service and its authorized representatives Statement Received by: and Corrective Action Dates Person in Charge: Date: IDSpected By: Packet Pg. 2409 "Schedule" MediCab rare or Cation DBA - Medicab Advantaqe, LLC Duns# 0 /4491489 1 Cage# IX1X0 Type: II MediCab-Transportation LLC. Inter -Facility Basic Life Support (BLS) 2020 Rate sheet Effective Date Au�_ust/ 020. *Trip rates as shown below` Rate Addition Rates Interfacility Non -Emergency (131-5) $400.00 Code A0428 Inter -facility Emergency (131-5) $450.00 Code A0429 Per loaded mile Code A0425 $10.00 PER MILE Oxygen $45.00 Code A0999 Drugs and IV supplies $10.00 - $25.00 (in 16e,1utam, fuel surcharges ma), tv applied to trips i%fuel rates increase to o%vr$3.DO per gallon) AUGUST 2020. This Rate Sheet covers all Basic Life Support interfacility Trips. 13Z+0 Not ih t.lwctand Rv;. unit r ;, iiottit : PI Sj4t13 rie�iwbt_r,ms ,cxn, 6t1' (239)1179 141W tM l.(s/'�j l l5 8itt Packet Pg. 2410 MediCab `ransportafion ORA - Medica6Advantapr UC r.na umei.+=1 uia �.�n. 15.A.3 CAPABILITY STATEMENT Basic Life Support (BLS) Transportation for Collier County Residents. ANY DATA DUNS: 074491489 Legal Name: MediCab Transportation LLC CAGE: 7X 1 XO NAILS: 485991, 485999. 492110, 488490. 485510. 561210 PSC: V225, 2310. V212, R602. V002 Certifications: Veteran -Owned Small Business (VOSB), Disadvantaged Minority -Owned Small Business. United Medical Transportation Providers Group (t1MTPG) memher. National Center for Veterans Institute for Procurement (VIP) Alumni 2017. We Accepts government credit and purchase cards. • Wheelchair Van Service • Stretcher Transport Service • Bariatric Wheelchair transport • Lab Courier Service • Bariatric Stretcher transport up 1000 • Blood Transportation pounds • Solutions to Complex Transportation Issues Like senior companionship In 2019 alone, we completed over 460,000 miles that translated to over 15,232 trips ✓ 9,490 wheelchair trips ✓ 4015 stretcher trips ✓ 347 bariatric stretcher trips ✓ 1,380 bariatric wheelchair trips ✓ Over 15,147 recorded safe wheelchair & stretcher trips Registered at www mvFloridamarketplace.com Past Performance Lee Health Care (Area 5 Hospitals) from 04/2014 - present. Non -emergency wheelchair and stretcher patient transport. Contact: Barbara Kenney, (239) 343-5649, Barbara KenneyCcDleehealth.ore Fort Myers Rehabilitation Center. from C'3/?09 5 . prpse r,`. Noo-emergene- :;she alchsir and stretcher patient transport. Contact: Tobias Breder, (239) 936-0203, Tbreder@ftmversrehab.com Lehigh Acres Regional Hospital from 02/2016-present. Non -emergency wheelchair and stretcher patient (Anita Social services) Calusa Harbour Rehab & Assisted Living, from 0 /20i.4 - present. Non -emergency wheelchair and stretcher patient transport. Contact: Jay Grossier, (239) 425-2241, JGrosser@5SQC.com Select Specialty Hospital — Fort Myers, from '); .% �I- to present Non -emergency wheelchair and stretcher patient Park Royal Behavioral Hospital, � `:-present. Non -emergency wheelchair and stretcher patient transport. Contact Director -Business Development (239) 462-2585 David Lawrence Center — Naples. The Willoughs — Naples. 13240 North Cleveland Ave suite 4, North Foi L MyE rs, FL 33901, www.medicabOans.wrn - .39-419-1444 Packet Pg. 2411 15.A.3 PRESIDENT MediCab Transportation LLC CONTACT PHONE: 239980-3900 https •//medicabtranS-corn EMAIL: maflin@tnedicabtralls-Coln Martin G. Ndungu (239)980-3900 3049 Cleveland Ave suite # 275 Fort Myers Florida 33901 Fax: 1(877) 745-8863 OBJECTIVE: Creating efficient resources and resourcefulness to medical transportation in all of Hendry and Lee Counties. SUMMARY OF QUALIFICATIONS • Entrepreneur founder MediCab Transportation LLC • Director of Economic Affairs (African Network of Southwest Florida). • CEO Sanibel Goatzs LLC an Electric Geo Fence Dockless Scooter Company • Former Active U.S Army and Florida National Guard • Team manager 6 years while in the U.S. Active Duty Army • Bilingual in English, Swahili and other dialects • Over 24 years of business leadership & managcmcni EXPERIENCE 2013— Present Business owner MediCab Transportation LLC Managing daily company operations and business development May 2009 — May 2015 Heavy Equipment Operator Manager U.S. Army Active DulylFL Guard Managed small teams, trained and equipped foreign troops.. Worked in conjunction with Border Patrol at several border related tasks resulting in savings of over one hundred sixty thousand dollars and completed project ahead of schedule Feb 2005 — April 2009 Sales Driver Arizona Beverage • Managed 58 customer accounts, averaged S 3900.00 daily cash sales and stock Feb 2004 — Dec 2007 Owner Operator MGN Trucking LLC.. Owned, managed and operated MGN Trucking LLC (OTR) EDUCATION • United states Army (WLC) training small team leadership • Kenya Institute of Mass Communication Advanced Diploma • Graduate Tony Robbins business Mastery Graduate Veteran Institute of Procuremcat • Graduate Goodwills Micro entrepreneur AFFILIATIONS: Affiliated with the Florida National Guard • Next Level Church, Fort Myers • Active Toastmasters International Cape Coral Member Keiser University Veterans Association • Director - Economic Affairs, African Network of SW Florida • Member — Sanibel Chamber of Commerce ACOLADES: Distinguished Entrepreneur Finalist (Honors) 2019 SBDC and FGCU- • Recognized by Governor Rick Scott Jan 2018 for Creating Jobs in Florida References: Dan Telep, Jr. Consultant SBDC 10501 FGCU Blvd. S Fort Myers, FL 33965 239-745-3708 Chris Hansen C.E.O at Child Care of Southwest Florida Inc. chrish!u`,ccswfl .or a Tet: (239) 462-2585 Dr. Peter Ndiangu'i Prof, FGCU Collagc of Education President African Network of Southwest Florida Tel: (404) 759-3604 Packet Pg. 2412 15.A.4 March 11, 2020 Naples, Florida MINUTES OF THE OF THE COLLIER COUNTY EMERGENCY MEDICAL AUTHORITY MEETING LET IT BE REMEMBERED, the Emergency Medical Authority in and for the County of Collier, having conducted business herein, met on this date at 9:30 AM in REGULAR SESSION at Collier County Government, 3301 Tamiami Trail East, Human Resources Training Room, Naples, Florida with the following members present: Vice Chair: Robert Chalhoub, Citizen Representative Dr. James Britton, Citizen Representative Ann Davis, Citizen Representative Bryce Alexander, Citizen Representative ALSO, PRESENT: Tabatha Butcher, Chief, EMS Bruce Gastineau, Assistant Chief, EMS Yolanda Garza, Admin Assistant, EMS 0 N O N Packet Pg. 2413 15.A.4 1. CALL TO ORDER AND PLEDGE OF ALLEGIANCE Meeting called to order at 9:30 am by Mr. Chalhoub. A quorum was established. 2. AGENDA AND MINUTES a. Approval of Today's Agenda Change to the agenda, introduction of new EMA members was moved to top of the list. Add to agenda, monitoring of statistics. Motion to approve agenda with changes by Dr. Britton. Second by Ms. Davis. Passed unanimously. b. Approval of the February 12, 2020 Meeting Minutes Motion to approve February minutes by Dr. Britton. Seconded by Mr. Alexander 3. OLD BUSINESS a. Performance Measures Update Chief Butcher discussed fractals. Response times and transports. Overdoses are down 17% for the month of February. Trauma alerts are also down. Hospital off loads, doing well. b. EMA Bylaws Mr. Chalhoub discussed revision of bylaws. New members will need time to get familiar with bylaws. Will revisit next month. Will not be voted on this month. Article 2.A. of the bi-laws suggestion to reinstate that the EMA members will be full time residents of the county. 4. NEW BUSINESS a. Introduction of New EMA Members Mrs. Davis introduced herself. Mr. Alexander introduced himself. 5. FIRE SERVICE DISCUSSION No comment 6. STAFF REPORTS Chief Butcher welcomed new members. Will set up one on one with Chief and new members to do ride along. We will be monitoring meetings due to the coronavirus. Chief Butcher discussed virus, new cases and affecting our county. Guidelines have been put in place. Limiting crew members that take calls. Four confirmed cases in Florida and 1 fatality in the state. EOC has not been activated. Helicopter is on the way. Paint booth in April. Packet Pg. 2414 15.A.4 Last Thursday a groundbreaking ceremony took place for station construction in Ave Maria. EMS will hold a Stope the Bleed Class for members, either March 23 1-3 pm or April loth 10-12 7. PUBLIC COMMENT None 8. BOARD MEMBER DISCUSSION EMA members would like to obtain monthly reports from all other transfer facilities. 9. ESTABLISH NEXT MEETING DATE a. September 9, 2020 at 9:30am HR Training Room 10. ADJOURNMENT Motion to adjourn meeting by Dr. Britton seconded by Mr. Alexander. Meeting adjourned at 10:25 am. Collier County Emergency Medical Authority Vice Chair, Robert Chalhoub These minutes approved by the Board/Committee on as presented as amended Packet Pg. 2415