EmailMe Form - CAMTS Global Application For Accreditation

CAMTS Global Application For Accreditation

1. Complete this initial application.

2. Return to the CAMTS Global office the 750.00 application fee.

3. You will then receive the Program Information Folder (PIF) by email.

4. You have up to 1 year to complete the PIF.

5. Submit the PIF and the attachments requested following the instructions on the PIF.

6. We will contact you to schedule your site visit after we receive your completed PIF.

7. An accreditation decision will be made at the next Board of Directors meeting.

Banking Info for Bank Transfer -

Wells Fargo Bank, N.A. (163) P.O. Box 6995 Portland, OR 97228-6995

Account number
2834747806

Routing numbers
Direct deposits & electronic payments 102000076
Domestic wire transfers 121000248
International wire transfers WFBIUS6S

Name of Medical Transport Service
Mailing address for main base of operationss

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Mailing address for corporate office

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Web Site
Name and Address of Hospital (if hospital affiliated)
Business Phone
Principle Contact
First Last
Title
Email
Phone
PIF Submission Goal Date
MM / YYYY
You will have one year from when you apply before this application expires.
Comments
How will you pay the application fee -
Check
Bank Transfer
(PIF will be emailed once we receive check)
You are responsible for all transfer fees.
Total number of bases
A base is defined as any place aircraft/ambulance and medical crew are located.
Aircraft Hull and Liability Insurance Certificate

Add File
Description of Service
(Check all that apply to your service)
Types of Service
RW (ALS)
RW (Critical Care)
FW (ALS)
FW (Critical Care)
Ground (ALS)
Ground (BLS)
Ground (Critical Care)
Medical Escort (Basic Care)
Medical Escort (Advanced Care)
Other Surface (boat, ATV, snowmobile etc.)
Special Operations
Transports Request Accepted

RW FW G ME Other Surface

Burns

Cardiac

IABP

Trauma

Pediatric (PICU)

High Risk OB

Adult

Neonatal
Size of the Service
(Dedicated aircraft/ambulance(s) are used for more than 1 transport per month for any consecutive six month period)

RW FW G ME Other Surface

Total number of transports in most recent fiscal year

Total number of dedicated aircraft/ambulance(s)
RW FW Ambulance and/or Other Surface ME

FAA Cert #/EASA Cert#/ TC Cert#/ Other (please state number and which it is)

Company Name/Owner/Operator

Address
Office use only -
Date received:
Program Number:
Entered into database:
Payment received:
Emailed PIF:
Sent Packet:

	RW	FW	G	ME	Other Surface
Burns
Cardiac
IABP
Trauma
Pediatric (PICU)
High Risk OB
Adult
Neonatal

	RW	FW	G	ME	Other Surface
Total number of transports in most recent fiscal year
Total number of dedicated aircraft/ambulance(s)

	RW	FW	Ambulance and/or Other Surface	ME
FAA Cert #/EASA Cert#/ TC Cert#/ Other (please state number and which it is)
Company Name/Owner/Operator
Address

Description of Service

Size of the Service

Office use only -