A.R.S. tit. 36 ch. 21.1 — Arizona Revised Statutes Title 36 Chapter 21.1 — Emergency Medical Services

36-2201. Definitions In this chapter, unless the context otherwise requires: 1. "Administrative medical direction" means supervision of emergency medical care technicians by a base hospital medical director, administrative medical director or basic life support medical director. For the purposes of this paragraph, "administrative medical director" means a physician who provides direction within the emergency medical services and trauma system. 2. "Advanced emergency medical technician" means a person who has been trained in an advanced emergency medical technician program certified by the director or in an equivalent training program and who is certified by the director to render services pursuant to section 36-2205. 3. "Advanced life support" means the level of assessment and care identified in the scope of practice approved by the director for the advanced emergency medical technician, emergency medical technician I-99 and paramedic. 4. "Advanced life support base hospital" means a health care institution that offers general medical and surgical services, that is certified by the director as an advanced life support base hospital and that is affiliated by written agreement with a licensed ambulance service, air ambulance service, municipal rescue service, fire department, fire district or health services district for medical direction, evaluation and control of emergency medical care technicians. 5. "Air ambulance" means any publicly or privately owned aircraft that is certificated under 14 Code of Federal Regulations part 135, that contains a stretcher and necessary medical equipment and supplies pursuant to section 36-2202 and that is specifically designed and constructed or modified and equipped to be used, maintained or operated primarily to transport individuals who are sick, injured or wounded or who require medical monitoring or aid. 6. "Air ambulance attendant" means any of the following: (a) A paramedic whose primary responsibility is caring for patients in an air ambulance and who meets the standards and criteria adopted pursuant to section 36-2204. (b) A respiratory therapist who is licensed pursuant to title 32, chapter 35. (c) A physician. (d) A professional nurse who is licensed pursuant to title 32, chapter 15 and whose primary responsibility is caring for patients in an air ambulance. (e) A nurse practitioner who is licensed pursuant to title 32, chapter 15. 7. "Air ambulance service" means a person or organization that owns and operates one or more air ambulances or that leases from an air carrier the use of one or more air ambulances that are certificated under 14 Code of Federal Regulations part 135 for the purpose of providing emergency medical services in air ambulances. 8. "Ambulance": (a) Means any publicly or privately owned surface or water vehicle that contains a stretcher and necessary medical equipment and supplies pursuant to section 36-2202 and that is specifically designed and constructed or modified and equipped to be used, maintained or operated primarily to transport individuals who are sick, injured or wounded or who require medical monitoring or aid. (b) Does not include a surface vehicle that is owned and operated by a private sole proprietor, partnership, private corporation or municipal corporation for the emergency transportation and in-transit care of its employees or a vehicle that is operated to accommodate an incapacitated person or person with a disability who does not require medical monitoring, care or treatment during transport and that is not advertised as having medical equipment and supplies or ambulance attendants. 9. "Ambulance attendant" means any of the following: (a) An emergency medical technician, an advanced emergency medical technician, an emergency medical technician I-99 or a paramedic whose primary responsibility is the care of patients in an ambulance and who meets the standards and criteria adopted pursuant to section 36-2204. (b) An emergency medical responder who is employed by an ambulance service operating under section 36-2202 and whose primary responsibility is driving an ambulance. (c) A physician. (d) A professional nurse who is licensed pursuant to title 32, chapter 15 and who meets the Arizona state board of nursing criteria to care for patients in the prehospital care system. (e) A professional nurse who is licensed pursuant to title 32, chapter 15 and whose primary responsibility is the care of patients in an ambulance during an interfacility transport. 10. "Ambulance service" means a person who owns and operates one or more ambulances. 11. "Basic life support" means the level of assessment and care identified in the scope of practice approved by the director for the emergency medical responder and emergency medical technician. 12. "Bureau" means the bureau of emergency medical services and trauma system in the department. 13. "Centralized medical direction communications center" means a facility that is housed within a hospital, medical center or trauma center or a freestanding communication center that meets the following criteria: (a) Has the ability to communicate with ambulance services and emergency medical services providers rendering patient care outside of the hospital setting via radio and telephone. (b) Is staffed twenty-four hours a day, seven days a week, by at least a physician. 14. "Certificate of necessity" means a certificate that is issued to an ambulance service by the department and that describes the following: (a) The service area. (b) The level of service. (c) The type of service. (d) The hours of operation. (e) The effective date. (f) The expiration date. (g) The legal name and address of the ambulance service. (h) The any limiting or special provisions the director prescribes. 15. "Council" means the emergency medical services council. 16. "Department" means the department of health services. 17. "Director" means the director of the department. 18. "Emergency medical care technician" means an individual who has been certified by the department as an emergency medical technician, an advanced emergency medical technician, an emergency medical technician I-99 or a paramedic. 19. "Emergency medical responder" as an ambulance attendant, whose primary responsibility is driving an ambulance, or an air ambulance attendant, means a person who has successfully completed training in an emergency medical responder program that is certified by the director or is approved by the emergency medical services provider's administrative medical director on file with the department or in an equivalent training program. 20. "Emergency medical responder program" means a program that has been submitted for review by the department and includes at least the following: (a) Emergency vehicle driver training. (b) Cardiopulmonary resuscitation certification. (c) Automated external defibrillator training. (d) Training in the use of noninvasive diagnostic devices, including blood glucose monitors and pulse oximeters. (e) Training on obtaining a patient's vital signs, including blood pressure, pulse and respiratory rate. 21. "Emergency medical services" means those services required following an accident or an emergency medical situation: (a) For on-site emergency medical care. (b) To transport the sick or injured by a licensed ambulance or air ambulance. (c) In using emergency communications media. (d) In using emergency receiving facilities. (e) In administering initial care and preliminary treatment procedures by emergency medical care technicians. 22. "Emergency medical services provider" means any governmental entity, quasi-governmental entity or corporation, whether public or private, that renders emergency medical services in this state. 23. "Emergency medical technician" means a person who has been trained in an emergency medical technician program certified by the director or in an equivalent training program and who is certified by the director as qualified to render services pursuant to section 36-2205. 24. "Emergency receiving facility" means a licensed health care institution that offers emergency medical services, is staffed twenty-four hours a day and has a physician on call. 25. "Epinephrine delivery system" means a single-use device or product that contains a premeasured dose of epinephrine and that is approved by the United States food and drug administration to prevent or treat a life-threatening allergic reaction. 26. "Fit and proper" means that the director determines that an applicant for a certificate of necessity or a certificate holder has the expertise, integrity, fiscal competence and resources to provide ambulance service in the service area. 27. "Medical record" means any patient record, including clinical records, prehospital care records, medical reports, laboratory reports and statements, any file, film, record or report or oral statements relating to diagnostic findings, treatment or outcome of patients, whether written, electronic or recorded, and any information from which a patient or the patient's family might be identified. 28. "National certification organization" means a national organization that tests and certifies the ability of an emergency medical care technician and whose tests are based on national education standards. 29. "National education standards" means the emergency medical services education standards of the United States department of transportation or other similar emergency medical services education standards developed by that department or its successor agency. 30. "Paramedic" means a person who has been trained in a paramedic program certified by the director or in an equivalent training program and who is certified by the director to render services pursuant to section 36-2205. 31. "Physician" means any person who is licensed pursuant to title 32, chapter 13 or 17. 32. "Police dog": (a) Means a specially trained dog that is owned or used by a law enforcement department or agency of this state or any political subdivision of this state and that is used in the course of the department's or agency's official work. (b) Includes a search and rescue dog, service dog, accelerant detection canine or other dog that is in use by the law enforcement department or agency for official duties. 33. "Stretcher van" means a vehicle that contains a stretcher and that is operated to accommodate an incapacitated person or person with a disability who does not require medical monitoring, aid, care or treatment during transport. 34. "Suboperation station" means a physical facility or location at which an ambulance service conducts operations for the dispatch of ambulances and personnel and that may be staffed twenty-four hours a day or less as determined by system use. 35. "Trauma center" means any acute care hospital that provides in-house twenty-four-hour daily dedicated trauma surgical services that is designated pursuant to section 36-2225. 36. "Trauma registry" means data collected by the department on trauma patients and on the incidence, causes, severity, outcomes and operation of a trauma system and its components. 37. "Trauma system" means an integrated and organized arrangement of health care resources having the specific capability to perform triage, transport and provide care. 38. "Validated testing procedure" means a testing procedure that includes practical skills, or attests practical skills proficiency on a form developed by the department by the educational training program, identified pursuant to section 36-2204, paragraph 2, that is certified as valid by an organization capable of determining testing procedure and testing content validity and that is recommended by the medical direction commission and the emergency medical services council before the director's approval. 39. "Wheelchair van" means a vehicle that contains or that is designed and constructed or modified to contain a wheelchair and that is operated to accommodate an incapacitated person or person with a disability who does not require medical monitoring, aid, care or treatment during transport. 36-2202. Duties of the director; qualifications of medical director A. The director shall: 1. Appoint a medical director of the emergency medical services and trauma system. 2. Adopt standards and criteria for the denial or granting of certification and recertification of emergency medical care technicians. These standards shall allow the department to certify qualified emergency medical care technicians who have completed statewide standardized training required under section 36-2204, paragraph 1 and a standardized certification test required under section 36-2204, paragraph 2, who hold valid certification with a national certification organization or who have completed training and testing by the United States armed forces at a level comparable to the national standards for emergency medical care technicians. Before the director may consider approving a statewide standardized training or a standardized certification test, or both, each of these must first be recommended by the medical direction commission and the emergency medical services council to ensure that the standardized training content is consistent with national education standards and that the standardized certification test examines comparable material to that examined in the tests of a national certification organization. Beginning on September 12, 2026 or on approval from the federal bureau of investigation, a person applying for initial certification as an emergency medical care technician pursuant to the emergency medical services personnel licensure interstate compact and in compliance with the requirements of section 36-2259 shall possess a valid fingerprint clearance card pursuant to title 41, chapter 12, article 3.1. 3. Adopt standards and criteria that pertain to the quality of emergency care pursuant to section 36-2204. 4. Adopt rules necessary to carry out this chapter. Each rule shall identify all sections and subsections of this chapter under which the rule was formulated. 5. Adopt reasonable medical equipment, supply, staffing and safety standards, criteria and procedures to issue a certificate of registration to operate an ambulance or air ambulance. 6. Maintain a state system for recertifying emergency medical care technicians, except as otherwise provided by section 36-2202.01, that is independent from any national certification organization recertification process. This system shall allow emergency medical care technicians to choose to be recertified under the state or the national certification organization recertification system subject to subsection H of this section. B. Emergency medical technicians who choose the state recertification process shall recertify in one of the following ways: 1. Successfully completing an emergency medical technician refresher course approved by the department. 2. Successfully completing an emergency medical technician challenge course approved by the department. 3. For emergency medical care technicians who are currently certified at the emergency medical technician level by the department, attesting on a form provided by the department that the applicant holds a valid and current cardiopulmonary resuscitation certification, has and will maintain documented proof of a minimum of twenty-four hours of continuing medical education within the last two years consistent with department rules and has functioned in the capacity of an emergency medical technician for at least two hundred forty hours during the last two years. C. After consultation with the emergency medical services council, the director may authorize pilot programs designed to improve the safety and efficiency of ambulance and air ambulance inspections for governmental or quasi-governmental entities that provide emergency medical services in this state. D. The rules, standards and criteria adopted by the director pursuant to subsection A, paragraphs 2, 3, 4 and 5 of this section shall be adopted in accordance with title 41, chapter 6, except that the director may adopt on an emergency basis pursuant to section 41-1026 rules relating to the regulation of ambulance services and air ambulance services in this state necessary to protect the public peace, health and safety in advance of adopting rules, standards and criteria as otherwise provided by this subsection. E. The director may waive the requirement for compliance with a protocol adopted pursuant to section 36-2205 if the director determines that the techniques, drug formularies or training makes the protocol inconsistent with contemporary medical practices. F. The director may suspend a protocol adopted pursuant to section 36-2205 if the director does all of the following: 1. Determines that the rule is not in the public's best interest. 2. Initiates procedures pursuant to title 41, chapter 6 to repeal the rule. 3. Notifies all interested parties in writing of the director's action and the reasons for that action. Parties interested in receiving notification shall submit a written request to the director. G. To be eligible for appointment as the medical director of the emergency medical services and trauma system, the person shall be qualified in emergency medicine and shall be licensed as a physician in one of the states of the United States. H. Applicants for certification shall apply to the director for certification. Emergency medical care technicians shall apply for recertification to the director every two years. The director may extend the expiration date of an emergency medical care technician's certificate for thirty days. The department shall establish a fee for this extension by rule. Emergency medical care technicians shall pass an examination administered by the department as a condition for recertification only if required to do so by the advanced life support base hospital's medical director or the emergency medical care technician's medical director. I. The medical director of the emergency medical services and trauma system is exempt from title 41, chapter 4, articles 5 and 6 and is entitled to receive compensation pursuant to section 38-611, subsection A. J. The standards, criteria and procedures adopted by the director pursuant to subsection A, paragraph 5 of this section shall require that ambulance services and air ambulances services: 1. Providing interfacility transportation, by an ambulance, in any certificate of necessity area of this state have one ambulance attendant as defined in section 36-2201, paragraph 9, subdivision (a), (c), (d) or (e) and one ambulance attendant as defined in section 36-2201, paragraph 9, subdivision (a), (b), (c), (d), or (e) staffing an ambulance while transporting a patient. If an ambulance attendant as defined in section 36-2201, paragraph 9, subdivision (b) is staffing the ambulance pursuant to this paragraph, that ambulance attendant may exclusively drive the ambulance. 2. Providing interfacility transportation, by an air ambulance, have one air ambulance attendant as defined in section 36-2201, paragraph 6, subdivision (c), (d) or (e) and one air ambulance attendant as defined in section 36-2201, paragraph 6, subdivision (a), (b) or (d) staffing an air ambulance while transporting a patient. 3. Serving a rural or wilderness certificate of necessity area with a population of less than ten thousand persons have at least one ambulance attendant as defined in section 36-2201, paragraph 9, subdivision (a), (c), (d) or (e) and one ambulance attendant as defined in section 36-2201, paragraph 9, subdivision (a) or (b) staffing an ambulance while transporting a patient. 4. Serving a population of ten thousand persons or more have at least one ambulance attendant as defined in section 36-2201, paragraph 9, subdivision (a) and one ambulance attendant as defined in section 36-2201, paragraph 9, subdivision (a), (c), (d) or (e) staffing an ambulance while transporting a patient. K. If the department determines there is not a qualified administrative medical director, the department shall ensure the provision of administrative medical direction for an emergency medical technician if the emergency medical technician meets all of the following criteria: 1. Is employed by a nonprofit or governmental provider employing less than twelve full-time emergency medical technicians. 2. Stipulates to the inability to secure a physician who is willing to provide administrative medical direction. 3. Stipulates that the provider agency does not provide administrative medical direction for its employees. 36-2202.01. Test administration The test for certification or recertification, pursuant to section 36-2202, may be administered by the department or one of the following approved by the director: 1. Representatives appointed by the director in consultation with the medical director of the emergency medical services and trauma system. 2. A testing facility. 3. An emergency medical services provider or ambulance service provider that has a training or education program. Emergency medical service providers or ambulance service providers may enter into contracts or intergovernmental agreements with other public entities for the purposes of emergency medical care technician testing and recertification testing. The training or education program must be staffed by at least three full-time persons who provide education and training to emergency services personnel. Two of these persons must be certified at a minimum of emergency medical care technician or higher and at least one person must be a paramedic or a registered nurse licensed pursuant to title 32, chapter 15. The medical director of an emergency medical training or education program must be a physician licensed pursuant to title 32, chapter 13 or 17. 36-2202.02. Sale or disclosure of information; prohibition; exception; definition A. The department may not sell or disclose any personal identifying information of an emergency medical care technician. The personal identifying information of an emergency medical care technician is confidential and, if a request for the personal identifying information is made for a commercial purpose, the personal identifying information is exempt from title 39, chapter 1, article 2. The department may disclose personal identifying information of an emergency medical care technician with the emergency medical care technician's consent that includes the information that may be disclosed and the purposes for the disclosure. B. The department may disclose information that has been de-identified or that is in an aggregated form and that does not reasonably allow the identification of an emergency medical care technician. C. This section does not prohibit the department from sharing information relating to the application for licensure or the licensure of an emergency medical care technician with another regulatory entity, including a commission that administers a licensure compact. D. This section does not prevent the department from disclosing information pertaining to an emergency medical technician's licensing history or record of disciplinary actions pursuant to section 36-2220. E. For the purposes of this section, "personal identifying information" includes: 1. A social security number, passport number, driver license number or taxpayer identification number. 2. A personal address, personal email address or personal telephone number. 3. A biometric record, including a photographic image, a fingerprint, a retinal scan, a voice signature or facial geometry. 4. Bulk information that when combined with other request details may pose a privacy risk, including: (a) Date of birth. (b) Place of birth. (c) Race. (d) Religion. (e) Geographic indicators. (f) Employment information. (g) Education information. 36-2203. Emergency medical services council; membership; delayed repeal A. The emergency medical services council is established. The medical director of the emergency medical services and trauma system shall chair the council. The council is composed of the director of the department of public safety and the governor's highway safety coordinator, or their designees, and the following members who are appointed by the governor to three-year terms: 1. One representative from each of the four local emergency medical services coordinating systems prescribed in section 36-2210. 2. One physician specializing in emergency medicine from each of the four local emergency medical services coordinating regions prescribed in section 36-2210. 3. One professional nurse who is licensed pursuant to title 32, chapter 15 and who specializes in emergency medicine. 4. One emergency medical care technician. 5. Two representatives from ambulance service corporations or air ambulance service corporations. 6. Two hospital administrators, one of whom represents a county with a population of less than five hundred thousand persons. 7. One representative from each of the three employers of the largest number of emergency medical care technicians and paramedics. 8. One representative from a nongovernmental employer of emergency medical technicians I-99. 9. One representative from the state fire districts. 10. One physician who is licensed pursuant to title 32, chapter 13 or 17 and who specializes in trauma surgery. 11. One representative of a prehospital emergency medical training program. 12. Six public members. 13. One representative of a volunteer medical rescue program. B. Public members of the council are eligible to receive compensation pursuant to section 38-611. C. This section is repealed from and after January 1, 2028. 36-2203.01. Medical direction commission; membership; duties A. The medical direction commission is established consisting of the following twelve members: 1. The medical director of the emergency medical services and trauma system in the department of health services who shall serve as chairman. 2. The four emergency physicians who serve on the emergency medical services council pursuant to section 36-2203, subsection A, paragraph 2. 3. One physician who specializes in toxicology and who has a demonstrated interest or expertise in emergency medical services systems. 4. One full-time faculty representative of an emergency medicine residency program approved by a residency review commission. 5. One physician who specializes in trauma surgery and who has a demonstrated interest or expertise in emergency medical services systems. 6. One emergency physician who has a full-time practice based in a rural area. 7. One physician who specializes in severe acute head injury treatment or spinal cord care and who has a demonstrated interest or expertise in emergency medical services systems. 8. One physician who specializes in pediatric medicine and who has a demonstrated interest or expertise in emergency medical services systems. 9. One physician who specializes in cardiac care and who has a demonstrated interest or expertise in emergency medical services systems. B. The governor shall make all appointments of members designated pursuant to subsection A, paragraphs 3 through 9 of this section. The governor may accept recommendations for the appointment of commission members from the following organizations: 1. The Arizona chapter of the American college of emergency physicians. 2. The Arizona chapter of the American college of surgeons. 3. The Arizona chapter of the American college of pediatrics. 4. The Arizona chapter of the American college of physicians. C. The commission shall assist the director in developing medical protocols governing the medical treatments, procedures, medications, training and techniques that may be administered or performed by each classification of emergency medical care technicians pursuant to section 36-2205. D. Members of the commission serve three year terms. E. Members of the commission are not entitled to compensation but are entitled to reimbursement of expenses pursuant to title 38, chapter 4, article 2. 36-2204. Medical control; standards and criteria The medical director of the statewide emergency medical services and trauma system, the emergency medical services council and the medical direction commission shall recommend to the director of the department the following standards and criteria that pertain to the quality of emergency patient care: 1. Statewide standardized training, certification and recertification standards for all classifications of emergency medical care technicians. 2. A standardized and validated testing procedure for all classifications of emergency medical care technicians. 3. Medical standards for certification and recertification of training programs for all classifications of emergency medical care technicians. 4. Standardized continuing education criteria for all classifications of emergency medical care technicians. 5. Medical standards for certification and recertification of certified emergency receiving facilities and advanced life support base hospitals and approval of physicians providing medical control or medical direction for any classification of emergency medical care technicians who are required to be under medical control or medical direction. 6. Standards and mechanisms for monitoring and ongoing evaluation of performance levels of all classifications of emergency medical care technicians, emergency receiving facilities and advanced life support base hospitals and approval of physicians providing medical control or medical direction for any classification of emergency medical care technicians who are required to be under medical control or medical direction. 7. Objective criteria and mechanisms for decertification of all classifications of emergency medical care technicians, emergency receiving facilities and advanced life support base hospitals and for disapproval of physicians providing medical control or medical direction for any classification of emergency care technicians who are required to be under medical control or medical direction. 8. Medical standards for nonphysician prehospital treatment and prehospital triage of patients requiring emergency medical services. 9. Standards for emergency medical dispatch training, including prearrival instructions. For the purposes of this paragraph, "emergency medical dispatch" means the receipt of calls requesting emergency medical services and the response of appropriate resources to the appropriate location. 10. Standards for a quality assurance process for components of the statewide emergency medical services and trauma system, including standards for maintaining the confidentiality of the information considered in the course of quality assurance and the records of the quality assurance activities pursuant to section 36-2403. 11. Standards for ambulance services, air ambulance services and medical transportation that give consideration to the differences between urban, rural and wilderness areas. 12. Standards to allow an ambulance to transport a patient to a health care institution that is licensed as a special hospital and that is physically connected to an emergency receiving facility. 36-2204.01. Emergency medical services providers; centralized medical direction communications center An ambulance service or emergency medical services provider may provide centralized medical direction through a centralized medical direction communications center. 36-2204.02. Emergency medical services providers; ambulance services; air ambulance services; investigations of employees A. In lieu of the requirements of section 36-2211, the director may authorize an ambulance service, air ambulance service or emergency medical services provider to investigate, discipline or determine the fitness of an employee to continue to provide patient care. This authority does not apply to the conviction of, a plea of guilty or no contest to or admission in a court proceeding to the elements of a felony. The employer listed on the emergency medical care technician's, ambulance attendant's or air ambulance attendant's certification or recertification application may limit the practice of the emergency medical care technician, ambulance attendant or air ambulance attendant during the investigation if the employer meets all of the following requirements: 1. Has separate investigative or supervisory staff to conduct an investigation. 2. Has an employee assistance program for counseling. 3. Has policies and procedures for drug testing through urinalysis or other generally accepted methods. 4. Has policies and procedures for monitoring personnel who are suspected of or who have been convicted of substance abuse. B. An ambulance service, air ambulance service or emergency medical services provider that conducts its own disciplinary investigations pursuant to subsection A of this section shall report the following to the medical director of the emergency medical services and trauma system: 1. The nature of the allegation. 2. The level of patient care being delivered by the employee and the supervision of the employee during the investigation or rehabilitative period, or both. 3. The final outcome of the investigation and the final recommendation on the employee's certification status. C. The decisions of the employer under this section are appealable under the employer's personnel policies and procedures. Except as provided in section 41-1092.08, subsection H, the final administrative decisions of the director are subject to judicial review pursuant to title 12, chapter 7, article 6. 36-2205. Permitted treatment and medication; certification requirement; protocols A. The director, in consultation with the medical director of the emergency medical services and trauma system, the emergency medical services council and the medical direction commission, shall establish protocols, which may include training criteria, governing the medical treatments, procedures, medications and techniques that may be administered or performed by each classification of emergency medical care technician. These protocols shall consider the differences in treatments and procedures for regional, urban, rural and wilderness areas and shall require that emergency medical care technicians authorized to perform advanced life support procedures render these treatments, procedures, medications or techniques only under the direction of a physician. B. The protocols adopted by the director pursuant to this section are exempt from title 41, chapter 6. C. Notwithstanding subsection B of this section, a person may petition the director, pursuant to section 41-1033, to amend a protocol adopted by the director. D. In consultation with the medical director of the emergency medical services and trauma system, the emergency medical services council and the medical direction commission, the director shall establish protocols for emergency medical providers to refer and advise a patient or transport a patient by the most appropriate means to the most appropriate provider of medical services based on the patient's condition. The protocols shall consider the differences in treatments and procedures for regional, urban, rural and wilderness areas and shall require that emergency medical care technicians authorized to perform advanced life support procedures render these treatments, procedures, medications or techniques only under the direction of a physician. E. The protocols established pursuant to subsection D of this section shall include triage and treatment protocols that allow all classifications of emergency medical care technicians responding to a person who has accessed 911, or a similar public dispatch number, for a condition that does not pose an immediate threat to life or limb to refer and advise a patient or transport a patient to the most appropriate health care institution, as defined in section 36-401, based on the patient's condition, taking into consideration factors including patient choice, the patient's health care provider, specialized health care facilities and local protocols. 36-2206. Immunity; emergency instructions A. Any health care provider licensed or certified to practice in this state who in good faith gives emergency instructions to emergency medical care technicians at the scene of an emergency is not liable for any civil damages as a result of issuing those instructions. B. Any emergency medical services or health care provider who in good faith provides prearrival instructions following the minimum standards established by the state pursuant to section 36-2204, paragraph 9 is not liable for any civil damages as a result of issuing these instructions. 36-2207. Authorization for political subdivisions to participate Any city, town, county, fire district or health service district of this state may budget for and expend monies for participation in emergency paramedic programs and may enter into intergovernmental agreements for the delivery of such services pursuant to title 11, chapter 7, article 3. 36-2208. Bureau of emergency medical services and trauma system A. There is established within the department a bureau of emergency medical services and trauma system that is responsible for coordinating, establishing and administering a statewide system of emergency medical services, trauma care and a trauma registry. B. This chapter does not prevent any individual, law enforcement officer, public agency or member of a city, town, fire district or volunteer fire department from rendering on-site emergency medical care or, if, in terms of the existing medical situation, it is deemed not advisable to await the arrival of an ambulance, from transporting emergency medical patients to a hospital or an emergency receiving facility, except that if any patient objects on religious grounds, that patient shall not be administered any medical treatment or be transported to a hospital or an emergency receiving facility. C. The director shall develop an annual statewide emergency medical and trauma services plan and submit that plan to the council for review and approval. The statewide plan shall then be submitted to the governor for final adoption. Before submitting the plan to the governor, the director shall accept comments from the authorized local agencies and governmental entities. D. A local emergency medical services coordinating system shall develop a regional emergency medical services plan that includes a needs assessment and submit the plan to the director and to the authorized local agencies within the area. The regional plans shall be integrated into the statewide plan by the department. E. The state plan shall contain a budget component for funding local and state emergency medical services systems from the emergency medical services operating fund established pursuant to section 36-2218 based on the needs assessment of the local emergency medical services coordinating system plans. The components shall be included in the department's budget through the normal appropriation process. 36-2209. Powers and duties of the director A. The director shall: 1. Appoint and define the duties and prescribe the terms of employment of all employees of the bureau. 2. Adopt rules necessary for the operation of the bureau and for carrying out the purposes of this chapter. 3. Cooperate with and assist the personnel of emergency receiving facilities and other health care institutions in preparing a plan to be followed by emergency receiving facilities and health care institutions in the event of a major disaster. 4. Cooperate with the state director of emergency management when a state of emergency or a state of war emergency has been declared by the governor. B. The director may: 1. Request the cooperation of utilities, communications media and public and private agencies to aid and assist in implementing and maintaining a statewide emergency medical services system. 2. Enter into contracts and agreements with any local governmental entity, agency, facility or group that provides a similar program of emergency medical services in a contiguous state. 3. Enter into contracts and agreements to acquire and purchase any equipment, tools, supplies, materials and services necessary to administer this chapter. 4. Enter into contracts with emergency receiving facilities, governmental entities, emergency rescue services, air ambulance services and ambulance services and establish emergency medical services, including emergency receiving facilities, if necessary to ensure the availability and quality of emergency medical services. 5. Accept and spend federal funds and private grants, gifts, contributions and devises to assist in carrying out the purposes of this chapter. These funds do not revert to the state general fund at the close of a fiscal year. 6. Establish an emergency medical services notification system that uses existing telephone communications networks. 7. Contract with private telephone companies to establish a statewide emergency reporting telephone number. 8. Authorize the testing entity to collect fees determined by the director. In determining fees for testing entities, the director shall consider the fees required by national certification organizations. 36-2210. Local emergency medical services coordinating systems The department shall contract with a local emergency medical services coordinating system that: 1. Conducts needs assessments and plans and coordinates a regional emergency medical and trauma services system within a designated planning area. 2. Has a governing board. 3. Demonstrates continued support annually by action of the governing bodies of the counties, cities, towns and fire districts within the planning area representing a majority of the total population of the area. For the purposes of this paragraph, the county represents the unincorporated areas of the county, except fire districts. 4. Offers emergency medical programs for the effective and coordinated delivery of emergency medical services if authorized by its governing board. 36-2211. Grounds for censure, probation, suspension or revocation of emergency medical care technician certificate; proceedings; civil penalty; judicial review A. The medical director of the emergency medical services and trauma system, on behalf of the director, may censure or place on probation an emergency medical care technician or suspend or revoke the certification issued to any emergency medical care technician pursuant to this article for any of the following causes: 1. Unprofessional conduct. 2. Conviction of, a plea of guilty or no contest to or admission in a court proceeding to the elements of a felony or of a misdemeanor involving moral turpitude during the time that a person is certified as an emergency medical care technician. The record of conviction or a copy of the record certified by the clerk of the court or by the judge by whom the person was sentenced is conclusive evidence of conviction. 3. Physical or mental incompetence to provide emergency medical services as an emergency medical care technician. 4. Gross incompetence or gross negligence in the provision of emergency medical services as an emergency medical care technician. 5. Wilful fraud or misrepresentation in the provision of emergency medical services as an emergency medical care technician or in the admission to that practice. 6. Use of any narcotic or dangerous drug or intoxicating beverage to an extent that the use impairs the ability to safely conduct the provision of emergency medical services as an emergency medical care technician. 7. The wilful violation of this chapter or the rules adopted pursuant to this chapter. B. The medical director of the emergency medical services and trauma system on the medical director's own motion may investigate any evidence that appears to show the existence of any of the causes set forth in subsection A of this section. The medical director shall investigate the report under oath of any person that appears to show the existence of any of the causes set forth in subsection A of this section. Any person reporting pursuant to this section who provides the information in good faith is not subject to liability for civil damages as a result. C. If, in the opinion of the medical director of the emergency medical services and trauma system, it appears the information is or may be true, the medical director shall request an informal interview with the emergency medical care technician. The interview shall be requested by the medical director in writing, stating the reasons for the interview and setting a date not less than ten days from the date of the notice for conducting the interview. The written request for an interview shall also state that if the medical director finds that cause exists for censure or probation or the suspension or revocation of the certificate the medical director may impose a civil penalty of not more than three hundred fifty dollars for each occurrence of cause as provided in subsection A of this section. The request for an interview shall also state that each day a cause for discipline exists constitutes a separate offense. D. Following the investigation, including an informal interview if requested, and together with any mental, physical or professional competence examination as the medical director of the emergency medical services and trauma system deems necessary, the medical director may proceed in the following manner: 1. If the medical director finds that the evidence obtained pursuant to subsections B and C of this section does not warrant censure or probation of the emergency medical care technician or suspension or revocation of a certificate, the medical director shall notify the emergency medical care technician and terminate the investigation. 2. If the medical director finds that the evidence obtained pursuant to subsections B and C of this section does not warrant suspension or revocation of a certificate but does warrant censure or probation, the medical director may do either of the following: (a) Issue a decree of censure. (b) Fix a period and terms of probation best adapted to protect the public health and safety and rehabilitate and educate the emergency medical care technician. Failure to comply with any probation is cause for filing a complaint and holding a formal hearing as provided in paragraph 3 of this subsection. 3. If the medical director finds that the evidence obtained pursuant to subsections B and C of this section warrants suspension or revocation of a certificate issued under this article, or if the emergency medical care technician under investigation refuses to attend the informal interview authorized in subsection C of this section, a complaint shall be issued and formal proceedings shall be initiated. All proceedings pursuant to this paragraph shall be conducted pursuant to title 41, chapter 6, article 10. E. If after a hearing as provided in this section any cause for censure, probation, suspension or revocation is found to exist, the emergency medical care technician is subject to censure or probation or suspension or revocation of the certificate or any combination of these for a period of time or permanently and under conditions as the medical director of the emergency medical services and trauma system deems appropriate. F. In addition to other disciplinary action provided pursuant to this section, the medical director of the emergency medical services and trauma system may impose a civil penalty of not more than three hundred fifty dollars for each occurrence of cause as provided in subsection A of this section not to exceed twenty-five hundred dollars. Each day that cause for discipline exists constitutes a separate offense. All monies collected pursuant to this subsection shall be deposited, pursuant to sections 35-146 and 35-147, in the state general fund. G. Except as provided in section 41-1092.08, subsection H, final decisions of the medical director of the emergency medical services and trauma system are subject to judicial review pursuant to title 12, chapter 7, article 6. 36-2212. Certificate of registration to operate an ambulance or air ambulance; termination on change in ownership; fees A. A person shall not operate an ambulance or air ambulance in this state unless the ambulance or air ambulance has a certificate of registration and complies with this article and the rules, standards and criteria adopted pursuant to this article. B. A person may obtain a certificate of registration to operate an ambulance or air ambulance by submitting an application on a form prescribed by the director and by demonstrating to the director's satisfaction that the applicant is in compliance with this article and all rules, standards and criteria adopted by the director for the operation of an ambulance or air ambulance. C. A certificate of registration issued under this section terminates on any change of ownership or control of the ambulance or air ambulance. Following any change of ownership, the new owner of an ambulance or air ambulance shall apply for and receive a new certificate of registration from the director before the ambulance or air ambulance may again be operated in this state. This subsection does not apply if an ambulance service or air ambulance service borrows, leases, rents or otherwise obtains a registered ambulance or air ambulance from another ambulance service or air ambulance service to temporarily replace an inoperable ambulance or air ambulance. D. The department shall issue a certificate of registration to a person that complies with the requirements of this article and that pays an initial registration fee. A certificate of registration is valid for one year, but an ambulance service or air ambulance service may request that the department issue an initial certificate of registration that expires before the end of one year in order for the department to conduct an annual inspection of all of the ambulance service's ambulances or air ambulance service's air ambulances at one time. A person may renew a certificate of registration by complying with the requirements of this article and by paying a renewal fee prescribed by the director. The fee for initial registration and registration renewal shall not exceed $50 for each ambulance or air ambulance. The department shall base these fees on an amount that approximates the per vehicle costs incurred by the department to administer this chapter. The director shall deposit, pursuant to sections 35-146 and 35-147, fees collected under this subsection in the state general fund. The department shall not charge a registration fee for an ambulance to an ambulance service that operates an ambulance or ambulances, or a registration fee for an air ambulance to an air ambulance service that operates an air ambulance or air ambulances, only as a volunteer not-for-profit service. 36-2213. Air ambulance services; rules The director shall adopt rules to establish minimum standards for the operation of air ambulance services that are necessary to ensure the public health and safety. The director may use the current standards adopted by the commission on accreditation of air medical services. Each rule shall reference the specific authority from this chapter under which the rule was formulated. The rules shall provide for the department to do the following: 1. Establish standards and requirements relating to at least the following: (a) Medical control plans. These plans shall conform to the standards adopted pursuant to section 36-2204, paragraph 9. (b) Qualifications of the medical director of the air ambulance services. (c) Operation of only those air ambulances registered pursuant to section 36-2212 and licensed pursuant to title 28, chapter 25. 2. Establish standards for emergency medical dispatch training, including prearrival instruction. For the purposes of this paragraph, "emergency medical dispatch" means the receipt of calls requesting emergency medical services and the response of appropriate resources to the appropriate location. 3. Require the filing of run log information. 4. Issue, transfer, suspend or revoke air ambulance service licenses under terms and conditions consistent with this chapter. These rules shall be consistent for all air ambulance services. 5. Investigate the operation of an air ambulance service, including a person operating an air ambulance that has not been issued a certificate of registration, and conduct on-site investigations of facilities communications equipment, vehicles, procedures, materials and equipment. 6. Prescribe the terms of the air ambulance service license. 7. Prescribe the criteria for the air ambulance service license inspection process and for determining an air ambulance service's compliance with licensure requirements. The director shall accept proof that an air ambulance service is accredited by the commission on accreditation of air medical services in lieu of all licensing inspections required if the director receives a copy of the air ambulance service's accreditation report. 36-2214. Air ambulance service license A. A person shall not operate an air ambulance service in this state unless the air ambulance service is licensed and complies with this article and the rules adopted pursuant to this article. B. On receipt of a properly completed application for initial licensure or relicensure on a form prescribed by the director, the director shall conduct an inspection of the air ambulance service as prescribed by this article. If an application for a license is submitted due to a planned change of ownership, the director shall determine the need for an inspection of the air ambulance service. C. The director shall issue a license if the director determines that an applicant and the air ambulance service for which the license is sought comply with the requirements of this article and rules adopted pursuant to this article and the applicant agrees to carry out a plan acceptable to the director to eliminate any deficiencies. 36-2215. Required insurance or financial responsibility; denial or revocation for failure to comply A. The director shall not issue an air ambulance service license to an air ambulance service unless the applicant for the license or the licensee files with the department a certificate of insurance completed by an insurance company that is authorized to transact business in this state or other evidence of financial responsibility in an amount that the director by rule determines is necessary to adequately protect the interest of the public. The applicant for a license or the licensee shall have malpractice and liability insurance that requires the insurer to compensate for injuries to persons and for loss or damage to property resulting from the negligent operation of the air ambulance service. B. The director shall deny the application for a license or revoke the license of any air ambulance service that fails to comply with this section. 36-2216. Prohibited acts; classification A. It is unlawful for any person to operate an ambulance or air ambulance in this state that does not comply with this article or the rules adopted by the director under this article. B. A person who violates subsection A of this section is guilty of a class 1 misdemeanor. 36-2217. Exemption from regulation A. This chapter does not apply to: 1. Vehicles used for the emergency transportation of persons injured at an industrial site. 2. Persons engaged in and vehicles used for air transportation of sick or injured people in a noncritical or nonemergency situation as determined by a physician. 3. Medical evacuation equipment used and owned by the department of public safety in air, ground or water evacuation and including fixed wing aircraft, helicopters, ground ambulances and similar ground conveyances, snowmobiles and water traversing equipment. 4. Vehicles provided or contracted for emergency medical services by a political subdivision if these vehicles are primarily used to provide on the scene stabilization of sick, injured, wounded, incapacitated or helpless persons. 5. Ambulances and air ambulances from other states that are: (a) Responding to a major catastrophe or emergency in this state because there are insufficient registered ambulances in this state to respond in that situation. (b) Operating either from a location outside of this state to transport a patient to a location within this state or operating from a location outside of this state and crossing through this state to transport a patient to a location outside this state. 6. Stretcher vans that meet the requirements of section 36-2223. B. Except as provided in subsection A, paragraph 5, subdivision (a) of this section, an ambulance or an air ambulance from another state shall not pick up a patient in this state and transport that patient to another location in this state unless that ambulance or air ambulance is registered under this chapter. 36-2218. Emergency medical services operating fund A. An emergency medical services operating fund is established. The director shall administer the fund. The emergency medical services operating fund shall consist of monies collected pursuant to sections 12-116.02 and 36-3251 and distributed pursuant to section 36-2219.01, subsection B, paragraph 2. B. The director of the department of health services with advice from the council shall expend monies in the fund for funding local and state emergency medical services systems. Monies in the fund are subject to annual legislative appropriation. 36-2219. Emergency medical care technicians; requirements; transportation A. An emergency medical care technician shall comply with either emergency medical standards and protocols established by the regional council or the medical direction for the local jurisdiction when considering emergency transport, including the appropriate use of telecommunications. B. An emergency medical care technician may not do either of the following: 1. Provide a patient with a presumptive medical diagnosis and use that medical diagnosis as the basis for counseling the patient to decline emergency medical services transportation. 2. Counsel a patient to decline emergency medical services transportation, except as part of a specific alternate destination or treat-and-refer program that includes quality management and comprehensive medical direction oversight. C. An emergency medical care technician shall explain to a patient the risks and consequences to the patient's health of not being transported. D. It is not a violation of this section for an emergency medical care technician to inform a patient of the patient's right to accept or decline emergency medical services transportation, unless the emergency medical care technician does so in an effort to coerce the patient to decline emergency medical services. 36-2219.01. Medical services enhancement fund A. A medical services enhancement fund is established consisting of monies collected pursuant to section 12-116.02. The state treasurer shall administer the fund. B. On the first day of each month, the state treasurer shall distribute or deposit: 1. Fourteen and two-tenths per cent in the substance abuse services fund established pursuant to section 36-2005. 2. Forty-eight and nine-tenths per cent in the emergency medical services operating fund established pursuant to section 36-2218 of which at least eight per cent shall be used for personnel expenses, education, training and equipment purchases in cities