1. A. No later than 30 days after the date of a change in the name listed on the ALS base hospital certificate, an ALS base hospital certificate holder shall notify the Department of the change, in a Department-provided format, including:

   1. 1. The current name of the ALS base hospital;
   2. 2. The ALS base hospital’s certificate number;
   3. 3. The new name and the effective date of the name change;
   4. 4. Documentation supporting the name change;
   5. 5. Documentation of compliance with the requirements in A.A.C. R9-10-109(A), if applicable;
   6. 6. Attestation that all information submitted to the Department is true and correct; and
   7. 7. The signature or electronic signature of the applicant’s chief administrative officer or the chief administrative officer’s designated representative and date of signature or electronic signature.

2. B. No later than 48 hours after changing the information provided according to R9-25-204(A)(1)(e) by terminating, adding, or amending a written agreement required in R9-25-203(B)(2), an ALS base hospital certificate holder shall notify the Department of the change, including:

   1. 1. The following information in a Department-provided format:

      1. a. The name of the ALS base hospital;
      2. b. The ALS base hospital’s certificate number; and

      3. c. As applicable, the name of the emergency medical services provider or ambulance service for which the ALS base hospital:

         1. i. Has a newly executed or amended written agreement described in A.R.S. § 36-2201(4), or
         2. ii. Is no longer providing administrative medical direction or on-line medical direction under a written agreement described in A.R.S. § 36-2201(4); and
   2. 2. If applicable, a copy of the newly executed or amended written agreement described in A.R.S. § 36-2201(4), including all attachments and exhibits.

3. C. No later than 10 days after the date of a change in an administrative medical director provided according to R9-25-204(A)(1)(f), an ALS base hospital certificate holder shall notify the Department of the change, in a Department-provided format, including:

   1. 1. The name of the ALS base hospital,
   2. 2. The ALS base hospital’s certificate number,
   3. 3. The name of the new administrative medical director and the effective date of the change,
   4. 4. Attestation that the new administrative medical director meets the requirements in R9-25-201(A)(1),
   5. 5. Attestation that all information submitted to the Department is true and correct, and
   6. 6. The signature or electronic signature of the applicant’s chief administrative officer or the chief administrative officer’s designated representative and date of signature or electronic signature.
4. D. No later than 30 days after the date of a change in the address listed on an ALS base hospital certificate or a change in ownership, as defined in A.A.C. R9-10-101, an ALS base hospital certificate holder shall submit to the Department an application required in R9-25-204(A).

Historical Note

Adopted effective October 15, 1996 (Supp. 96-4). Section repealed; new Section made by final rulemaking at 9 A.A.R. 5372, effective January 3, 2004 (Supp. 03-4). Amended by final rulemaking at 13 A.A.R. 3014, effective October 6, 2007 (Supp. 07-3). Section R9-25-205 repealed; new Section R9-25-205 renumbered from R9-25-209 and amended by exempt rulemaking at 19 A.A.R. 4032, effective December 1, 2013 (Supp. 13-4). Amended by final rulemaking at 25 A.A.R. 953, effective July 1, 2019 (Supp. 19-2).