ARSD 44:05:07:01. Application form

An application for a hardship exemption must include: (1) The name of the ambulance service; (2) The ambulance service owner’s or chief executive officer’s name, official title, address, email address, and phone number; (3) Documentation that the ambulance service solicited applications from family medicine, internal medicine, emergency medicine, or other qualified medical specialty physicians who are within a fifty-mile radius of the ambulance service coverage area and credentialed to work at the primary receiving facility for the ambulance service and from whom no applications were received; (4) Documentation that any fee that might be charged by physician willing and available to serve as the medical director is not reasonable and customary and would pose a financial hardship to the ambulance service; and (5) The name, credentials, and contact information for the program director being requested. An application must be received by the department at least thirty days prior to the intended start date of the program director.