Section 13 - Air Ambulance Licensing
13.1 	Purpose and Scope
These rules are promulgated pursuant to Section 25-3.5-307, C.R.S. (2007).
13.2 	Definitions
1.	Air Ambulance: A fixed-wing or rotor-wing aircraft that is equipped to provide air transportation and is specifically designed to accommodate the medical needs of individuals who are ill, injured, or otherwise mentally or physically incapacitated and who require in-flight medical supervision.
2.	Air Ambulance License: A legal document issued by the department as evidence that an air ambulance service meets the requirements for licensing as defined in these rules.
3.	Air Ambulance Service: Any governmental or private organization licensed by the department to transport in an aircraft patient(s) who require in-flight medical supervision to a medical facility.
4.	Aircraft: A rotor or fixed wing vehicle.
5.	Commission on Accreditation of Medical Transport Systems (CAMTS): A national not for profit organization that provides accreditation services for air medical and inter-facility transport services.
6.	Department: The Colorado Department of Public Health and Environment.
7.	Federal Aviation Regulations (FAR): Regulations promulgated by the Federal Aviation Administration of the U.S. Department of Transportation, governing the operation of all aircraft in the United States.
8.	Medical Protocol: Written standards for patient medical assessment and management.
9.	Patient Care Report (PCR): A medical record of an encounter between any patient and a provider of medical care.
10.	Rescue Unit: Any organized group chartered by this state as a corporation not for profit or otherwise existing as a nonprofit organization whose purpose is the search for and the rescue of lost or injured persons and includes, but is not limited to, such groups as search and rescue, mountain rescue, ski patrols, (either volunteer or professional), law enforcement posses, civil defense units, or other organizations of governmental designation responsible for search and rescue.
13.3 	Licensing
1.	Licensing Required
Upon the effective date of these rules, no person, agency, or entity, private or public, shall transport a sick or injured person by aircraft from any point within Colorado, to any point within or outside Colorado unless that person, agency, or entity holds a valid air ambulance service license to do so that has been issued by the department, except as provided in subsection 13.3,2 and 3 of these rules.
2.	Exception from Licensing-Exigent Circumstances	
Upon request, the department may authorize an air ambulance service to provide a particular transport upon a showing of exigent circumstances.  Exigent circumstances include but are not limited to:
A.	A humanitarian transport as determined by the department. In determining whether to authorize a humanitarian transport, the department shall consider the following factors:
(1)	Whether the transport is provided directly or indirectly by an organization whose mission is primarily dedicated toward non-profit or charitable or community care services;
(2)	Other available options for the transport;
(3)	Whether the transport will be of no cost to the patient;
(4)	Whether the transport is subsidized by a person or entity associated with the patient;
(5)	The qualifications of the transport personnel;
(6)	Information obtained from facilities and/or staff involved in the transport;
(7)	The air ambulance service’s membership in organizations that support safe medical care;
(8)	Air ambulance service insurance coverage as applicable;
(9)	Authorization under local and federal laws to conduct operations;
(10)	Licensure in other states or by other governmental agencies;
(11)	The air ambulance service’s safety record;
(12)	Whether or not the air ambulance service has been subject to disciplinary sanctions in other jurisdictions;
(13)	The air ambulance service’s prior contacts with the department, if any; and
(14)	Any other considerations deemed relevant by the department on a case by case basis.
B.	A disaster or mass casualty event in Colorado that limits the availability of licensed services;
C.	A need for specialized equipment not otherwise readily available through Colorado licensed air ambulance services.
3.	Licensing Not Required
A.	An air ambulance service agency that solely transports patients from points originating outside Colorado is not required to be licensed in Colorado.
B.	Rescue unit aircraft that are not specifically designed to accommodate the medical needs of individuals who are ill, injured, or otherwise mentally or physically incapacitated and who require in-flight medical supervision.
13.4	Out of State Air Ambulance Services Licensing Requirements
Air ambulance services that are based outside the state, but pick up patients in Colorado, are required to be licensed in Colorado by the department, except as provided in section 13.3,2 of these rules.
13.5	Application for Licensing
1.	At the time of application, applicants must be in compliance with all Federal Aviation Regulations such as proof of insurance, aircraft inspection certificates, Federal Aviation Administration part 135 certificate and Federal Communications Commission part 90.
2.	Accreditation by CAMTS.  Except as provided in 13.5,3 below, applicants that are currently accredited by CAMTS may receive a license to operate an air ambulance service upon completion of the documentation and fees that are required by the department and proof of such accreditation.
3.	The department may issue a conditional license to an applicant that has not yet received CAMTS accreditation upon proof that the applicant is actively working toward CAMTS accreditation.  The department may require that such proof be verified by CAMTS.  Any applicant that receives a conditional license shall complete its CAMTS accreditation within two years after issuance of the initial conditional license.
4.	If the holder of a conditional license fails to complete CAMTS accreditation within two years after the issuance of the initial conditional license, its conditional license shall be revoked and no license of any type shall be issued until it demonstrates successful completion of CAMTS accreditation.
5.	At such time as any air ambulance service licensed under section 13.3,1 of these rules receives a "notification of potential withdrawal of accreditation" from CAMTS, or is no longer CAMTS accredited, the service shall immediately notify the department.
13.6 	Fees
All applicants seeking licensure by the department under these air ambulance service rules shall submit the following non-refundable fees with each initial or renewal licensure application:
1.	$860 for each air ambulance service, plus $100 for each aircraft used by the air ambulance service.
2.	For applicants who are not CAMTS accredited, the applicant shall pay a fee of $525 to the department in addition to the fee set forth in 13.6,1 above.
13.7	Licensing Process
1.	To become licensed and maintain licensed status as an air ambulance service, the service shall:
A.	Achieve and maintain CAMTS accreditation.
B.	Demonstrate compliance with applicable federal, state, and local laws and regulations to operate a business in Colorado.
C.	Submit to the department a completed application form and the required application fee.
D.	Demonstrate compliance with these rules.
E.	Upon request, submit to the department copies of the service's written policy and procedure manual, operation/medical protocols, and other documentation the department may deem necessary.
2.	The department may conduct an inspection of the service and its aircraft to assure compliance with these rules.
3.	When change of ownership of an air ambulance service occurs, the new owner or operator must file for and obtain an air ambulance service license from the department prior to beginning operations.
13.8	Licensing Period
Any air ambulance service license issued by the department shall be valid for a period not to exceed one year.
13.9	Licensing Renewal
1.	To renew an existing air ambulance service license, the licensee shall submit a renewal application and fees, as set by the department, no later than three (3) months prior to the date of license expiration.
2.	A renewal inspection may be required by the department to assure service compliance with these rules.
13.10	Types of Service
In order to identify the types of services to be provided, air ambulance licenses shall be issued for each of the following types of service.
1.	Rotor wing advanced life support (RW-ALS)
2.	Rotor wing critical care (RW-CC)
3.	Rotor wing specialty care (RW-SC)
4.	Fixed wing basic life support (FW-BLS)
5.	Fixed wing advanced life support (FW-ALS)
6.	Fixed wing critical care (FW-CC)
7.	Fixed wing specialty care (FW-SC)
13.11	General Operational Requirements
1.	Each air ambulance service shall work in coordination with all other air ambulance services to assure optimal minimal response times.
2.	Policies for responding to requests for services shall include:
A.	Consultation with the requesting party regarding how and to whom those flights will be referred, based on the air ambulance service's scope of service, geographical proximity, transport capability and type of call.
B.	The closest appropriate service shall be dispatched unless a specific air ambulance service is requested by the requesting party.
C.	All air ambulance services must have a communications system in place capable of providing appropriate, timely referrals.
D.	Factors affecting the estimated time of arrival (ETA) of air ambulance service shall be communicated to the calling party as soon as possible, within five (5) minutes for inter-facility transports and three (3) minutes for scene requests.
E.	Scene requests shall be referred within three (3) minutes to the next closest, available, appropriate resource if the initial requested air ambulance service does not have an aircraft and crew immediately available.
F.	Inter-facility transport requests shall be referred within five (5) minutes to the next closest, available, appropriate resource if the initial requested air ambulance service does not have an aircraft and crew immediately available.
G.	Air ambulance service response policies and times shall be available to the public, upon request.
H.	In accordance with Section 11 of these rules, Colorado licensed air ambulance services shall complete a patient care report (PCR) to include the minimum pre-hospital care data set for each patient that is transported.  The minimum data elements identified by the department shall be compiled and submitted to the department in a format and frequency specified by the department.
I.	Each licensed air ambulance service shall complete and submit to the department an agency profile to provide information on resources available for planning and coordination of statewide emergency medical and trauma services.
13.12	Complaints
Complaints in writing relating to the quality and conduct of any air ambulance service may be made by any person or may be initiated by the department.  The department may make inquiry as to the validity of such complaint prior to initiating an investigation.  If the department determines that the complaint warrants a more extensive review, an investigation may be initiated.  If the complaint does not warrant further review or the inquiry determines that the complaint is not within regulatory jurisdiction of the department, the department will notify the complainant of the results of the inquiry.  The department shall refer complaints that are related to the requirements of CAMTS or a successor organization to CAMTS or such successor organization for investigation. The department may forward complaints to other regulatory agencies.
13.13	Denial, Revocation, Suspension, Summary Suspension, or Limitations of Air Ambulance Licenses
1.	If the department proposes for good cause to deny, revoke, suspend, summarily suspend or limit the license of an air ambulance service, the department shall notify the air ambulance service of its right to appeal the denial, revocation, suspension, summary suspension, or limitation, and the procedure for appealing.  Appeals of departmental denials, revocations, suspensions, summary suspensions, or limitations shall be conducted in accordance with the State Administrative Procedure Act, Section 24-4-101, et seq., C.R.S.
2.	In accordance with Section 24-4-104(4) C.R.S., the department may summarily suspend an air ambulance service license when the department has objective and reasonable grounds to believe and finds, upon a full investigation, that the holder of the license has been guilty of deliberate and willful violation or that the public health, safety or welfare imperatively requires emergency action by the department.  If the department summarily suspends a license, the department shall provide the air ambulance service with notice of such suspension in writing.  The notice shall state that the air ambulance service is entitled to a prompt hearing on the matter.
3.	Good cause for sanctions include but are not limited to:
A.	An applicant or licensee who fails to meet the requirements for licensing as set forth in these rules.
B.	An applicant or licensee who has committed fraud, misrepresentation, or deception in applying for a license.
C.	Falsifying reporting information provided to the department.
D.	Violating any state or federal statute, rule or regulation that would jeopardize the health or safety of a patient or the public.
E.	Unprofessional conduct, which hinders, delays, eliminates, or deters the provision of medical care to the patient or endangers the safety of the public.
F.	Failure to achieve or maintain CAMTS accreditation.
13.14	General Requirements
1.	These rules incorporate by reference the following materials:
A.	For services whose most recent application for CAMTS accreditation was submitted prior to January 1, 2007: the Accreditation Standards of the Commission on Accreditation of Medical Transport Systems (CAMTS), Sixth Edition, published October 2004.
B.	For services whose most recent application for CAMTS accreditation is submitted on or after January 1, 2007: the Accreditation Standards of the Commission on Accreditation of Medical Transport Systems (CAMTS), Seventh Edition, published September 2006.
C.	Such incorporation does not include later amendments to or editions of the referenced material.  The Health Facilities and Emergency Medical Services Division of the Colorado Department of Public Health and Environment maintains copies of the complete text of the incorporated materials for public inspection during regular business hours, and shall provide certified copies of any non-copyrighted material to the public at cost upon request.  Information regarding how the incorporated materials may be obtained or examined is available from the division by contacting:
EMTS Section Chief
Health Facilities and EMS Division
Colorado Department of Public Health and Environment
4300 Cherry Creek Drive South
Denver, Colorado 80246-1530
2.	These materials have been submitted to the state publications depository and distribution center and are available for interlibrary loans.  The incorporated material may be examined at any state publications depository library.