Common use of AGREEMENT RENEWAL Clause in Contracts

AGREEMENT RENEWAL. Check Level of Service: Basic Intermediate Advanced Name of Ambulance, Air Ambulance, or Fire-fighting Agency Mailing Address of Agency Phone Number of Agency Fax Number of Agency E-Mail Address of Agency Service or Agency Contact Person Title Approval is effective so long as the service or agency is operated as set forth in this agreement and is in compliance with Nevada Revised Statues and Nevada Administrative Code 450B. Approval is rescinded by the Division of Public and Behavioral Health for cause or on written request of the operating service or agency. NEVADA STATE EMS PROGRAM ONLY Date Received: Approved: Denied: Denial Letter Sent: Registered #: Date Reviewed: Documents Received: Attendant List Agreement Renewal Cover Physician Director Agreement Hospital(s) Agreement Service Agreement Mechanical Safety Statement Variance Review Current Rate Schedule Verification of Protocol Permitted Services Info Permit and Vehicle Fees All Permitted Agencies Once you have completed your review of all required documentation, the agency EMS Coordinator and the agency Medical Director must sign the bottom of this form attesting to the accuracy of the information provided. Please forward the updated packet to the Xxxxxx City Office. If you have any questions about any of the required documentation, or changes, please contact your EMS Representative. Checklist      Agreement Renewal Cover Letter Ambulance Service Agreement Physician Director Agreement Hospital Agreement    Permitted Services Information Verification of Current Protocols Current Rate Schedule  Vehicle Log (With Corrections If Necessary) Certification of Vehicle Mechanical Safety Attendant List Please make sure you have all this information on file for Site Audit Review when requested. EMS Coordinator (printed name) Medical Director (printed name) EMS Coordinator (signature) Medical Director (signature) VERIFICATION OF CURRENT PROTOCOLS Pursuant to NAC 450B.505 (2):

AGREEMENT RENEWAL. Check Level of Service: Basic Intermediate Advanced Name of Ambulance, Air Ambulance, or Fire-fighting Agency Mailing Address of Agency Phone Number of Agency Fax Number of Agency E-Mail Address of Agency Service or Agency Contact Person Title Approval is effective so long as the service or agency is operated as set forth in this agreement and is in compliance with Nevada Revised Statues and Nevada Administrative Code 450B. Approval is rescinded by the Division of Public and Behavioral Health for cause or on written request of the operating service or agency. NEVADA STATE EMS PROGRAM ONLY Date Received: Approved: Denied: Denial Letter Sent: Registered #: Date Reviewed: Documents Received: Attendant List Agreement Renewal Cover Physician Director Agreement Hospital(s) Agreement Service Agreement Mechanical Safety Statement Variance Review Current Rate Schedule Verification of Protocol Permitted Services Info Permit and Vehicle Fees All Permitted Agencies Once you have completed your review of all required documentation, the agency EMS Coordinator and the agency Medical Director must sign the bottom of this form attesting to the accuracy of the information provided. Please forward the updated packet to the Xxxxxx City Office. If you have any questions about any of the required documentation, or changes, please contact your EMS Representative. Checklist      🞏 🞏 🞏 🞏 Agreement Renewal Cover Letter Ambulance Service Agreement Physician Director Agreement Hospital Agreement    🞏 🞏 🞏 Permitted Services Information Verification of Current Protocols Current Rate Schedule  🞏 🞏 Vehicle Log (With Corrections If Necessary) Certification of Vehicle Mechanical Safety Attendant List Please make sure you have all this information on file for Site Audit Review when requested. EMS Coordinator (printed name) Medical Director (printed name) EMS Coordinator (signature) Medical Director (signature) VERIFICATION OF CURRENT PROTOCOLS Pursuant to NAC 450B.505 (2):

AGREEMENT RENEWAL. Check Level of Service: Basic Intermediate Advanced Name of Ambulance, Air Ambulance, or Fire-fighting Agency Mailing Address of Agency Phone Number of Agency Fax Number of Agency E-Mail Address of Agency Service or Agency Contact Person Title Approval is effective so long as the service or agency is operated as set forth in this agreement and is in compliance with Nevada Revised Statues and Nevada Administrative Code 450B. Approval is rescinded by the Division of Public and Behavioral Health for cause or on written request of the operating service or agency. NEVADA STATE EMS PROGRAM ONLY Date Received: Approved: Denied: Denial Letter Sent: Registered #: Date Reviewed: Documents Received: Attendant List Agreement Renewal Cover Physician Director Agreement Hospital(s) Agreement Service Agreement Mechanical Safety Statement Variance Review Current Rate Schedule Verification of Protocol Permitted Services Info Permit and Vehicle Fees All Permitted Agencies Once you have completed your review of all required documentation, the agency EMS Coordinator and the agency Medical Director must sign the bottom of this form attesting to the accuracy of the information provided. Please forward the updated packet to the Xxxxxx City Office. If you have any questions about any of the required documentation, or changes, please contact your EMS Representative. Checklist      Agreement Renewal Cover Letter Ambulance Service Agreement Physician Director Agreement Hospital Agreement    Permitted Services Information Verification of Current Protocols Current Rate Schedule   Vehicle Log (With Corrections If Necessary) Certification of Vehicle Mechanical Safety Attendant List All the above information, if not changed, is currently on file at with the State EMS Program. Please make sure you have all this information on file for Site Audit Review when requested. EMS Coordinator (printed name) Medical Director (printed name) EMS Coordinator (signature) Medical Director (signature) VERIFICATION OF CURRENT PROTOCOLS Pursuant to NAC 450B.505 (2):

AGREEMENT RENEWAL. Check Level of Service: Basic Intermediate Advanced Name of Ambulance, Air Ambulance, or Fire-fighting Agency Mailing Address of Agency Phone Number of Agency Fax Number of Agency E-Mail Address of Agency Service or Agency Contact Person Title Approval is effective so long as the service or agency is operated as set forth in this agreement and is in compliance with Nevada Revised Statues and Nevada Administrative Code 450B. Approval is rescinded by the Division of Public and Behavioral Health for cause or on written request of the operating service or agency. NEVADA STATE EMS PROGRAM ONLY Date Received: Approved: Denied: Denial Letter Sent: Registered #: Date Reviewed: Documents Received: Attendant List Agreement Renewal Cover Physician Director Agreement Hospital(s) Agreement Service Agreement Mechanical Safety Statement Variance Review Current Rate Schedule Verification of Protocol Permitted Services Info Permit and Vehicle Fees All Permitted Agencies Once you have completed your review of all required documentation, the agency EMS Coordinator and the agency Medical Director must sign the bottom of this form attesting to the accuracy of the information provided. Please forward the updated packet to the Xxxxxx City Office. If you have any questions about any of the required documentation, or changes, please contact your EMS Representative. Checklist      🞏 🞏 🞏 🞏 Agreement Renewal Cover Letter Ambulance Service Agreement Physician Director Agreement Hospital Agreement    🞏 🞏 🞏 Permitted Services Information Verification of Current Protocols Current Rate Schedule  🞏 🞏 🞏 Vehicle Log (With Corrections If Necessary) Certification of Vehicle Mechanical Safety Attendant List All the above information, if not changed, is currently on file at with the State EMS Program. Please make sure you have all this information on file for Site Audit Review when requested. EMS Coordinator (printed name) Medical Director (printed name) EMS Coordinator (signature) Medical Director (signature) VERIFICATION OF CURRENT PROTOCOLS Pursuant to NAC 450B.505 (2):