Get Copcn Application - Polk County Bocc

This guide provides a step-by-step approach to filling out the Certificate of Public Convenience and Necessity (COPCN) Application for Polk County. Whether you are applying for the first time or renewing an existing certificate, this document will outline the necessary components and instructions to complete the application successfully.

Follow the steps to correctly complete the COPCN Application.

1. Use the ‘Get Form’ button to access the COPCN Application document and open it in your selected editor.
2. Choose the type of application you are submitting: Initial or Renewal. Clearly mark the appropriate option.
3. Provide your business name, address, and contact information in the designated fields. Ensure you include all necessary details such as city, state, zip code, and phone numbers with area codes.
4. List the names, addresses, and daytime phone numbers of all owners, partners, operators, and board members as requested.
5. Detail the experience of each individual listed in the previous step to highlight qualifications.
6. Indicate the level of service you intend to provide by selecting from the options provided, referring to Polk County Ordinance 12-029 for detailed definitions.
7. Specify the geographical area you plan to serve, ensuring clarity on whether it encompasses the full county or parts of it.
8. State the reasons indicating the demand or need for the level of service in your chosen geographical area.
9. Describe the equipment you will use for the service; attach additional sheets if necessary. Complete the vehicle roster as instructed.
10. Indicate the number of personnel required to staff each unit and complete the personnel roster.
11. Provide proof of compliance with federal, state, and local requirements by attaching necessary certificates, including relevant licenses.
12. Detail the addresses and operational descriptions of the locations you will use, including hours of operation, staffing, and contact numbers.
13. Assess and state whether your service has back-up availability if equipment breaks down, and explain your procedure if applicable.
14. Submit documentation to assist Polk County Fire Rescue and other emergency services during a disaster, as required.
15. Answer whether your service will transport patients out of the county.
16. Indicate if your service will pick up patients from other counties and return them to Polk County.
17. Specify the type of service you will provide, marking land, water, or air as applicable.
18. If applicable, provide evidence for replacing an existing COPCN, including reasons for the change.
19. Include a non-refundable application fee of $300 with your submission.
20. List all rates and charges for the services you will provide in accordance with the application.
21. Acknowledge the agreement terms related to ongoing compliance, service provision, and operational guidelines, followed by your signature, title, and date.
22. Once completed, save changes and choose the option to download, print, or share the COPCN Application as needed.

Complete your COPCN Application online today to ensure timely processing.