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Ambulance Restocking Policy A. PURPOSE: To serve a significant public interest by allowing ambulances to depart the hospital stocked for the next emergency call. B. POLICY: Hospital will replenish medications, linens, and medical/surgical supplies to all non-charging ambulance providers at no cost to such ambulance providers. For charging ambulance providers, Hospital will provide a trade out for clean linens to such ambulance providers at no cost. The Ambulance Restocking Program adheres to the requirements of the safe harbor for ambulance restocking programs issued by the Office of the Inspector General for the Department of Health and Human Services. C. PROCEDURE: 1. A transfer of drugs and/or medical supplies, including linens, to a non-charging ambulance provider, will be only for the purpose of replenishing comparable drugs or medical supplies used by the ambulance provider in connection with the transport of a patient by ambulance to Hospital. A trade out of clean linens to a charging ambulance provider will be only for the purposes of replacing linens that were soiled during the transport of a patient by the ambulance provider to Hospital. 2. The ambulance that is replenished must be used to provide emergency ambulance services. 3. Federal health care programs must be appropriately billed. Hospital cannot bill for items provided through the restocking program. 4. Documentation will be maintained by the Hospital as follows: a. Records of the replenished drugs and medical supplies and the patient transport to which the replenished drugs and medical supplies relate will be maintained by the Hospital for 5 years. Ambulance providers will document requested drugs and/or supplies on the Supply Request Sheet and attach it to the goldenrod copy of the Ambulance Run Sheet. b. Records will be made available to the ambulance provider upon request. c. Records will be made available to the Department of Health and Human Services upon request. 5. The replenishing arrangement will not be tied to referrals. 6. Hospital and the ambulance provider will comply with all federal, state and local laws regulating ambulance services, including, but not limited to, laws relating to controlled substances. 7. Hospital will restock supplies on an equal basis for all non-charging ambulance providers. Hospital will trade out clean linens for all charging ambulance providers on an equal basis. 8. Hospital will post a written disclosure of the replenishing program in the Emergency Department. Copies of the disclosure shall be made available upon request to ambulance provides, government representatives and members of the public. A copy of this disclosure is attached. ATTACHMENTS: Notice of Ambulance Restocking Program Notice of Ambulance Restocking Program Hospital offers the following ambulance restocking program: 1. We will restock ambulance providers of emergency services that bring patients to Hospital in the following categories: (a) ambulance providers that do not charge patients or insurers for their services will be offered restocking of supplies and drugs utilized during transport and (b) ambulance providers that charge patients or insurers for their services will be offered a trade out for clean linens to replace soiled linens utilized during transport. 2. We only offer restocking of emergency transports to Hospital. 3. The restocking will include drugs and medical supplies, and linens, used for patient prior to delivery of the patient to Hospital. Drugs and medical supplies not stocked by Hospital will not be replenished. Only drugs and medical supplies of equivalent quantity or volume will be replenished. 4. The ambulance providers will not be required to pay for the restocked drugs and medical supplies, and linens. 5. The restocked drugs and medical supplies, and linens, must be documented as follows: Record information on the Supply Request Sheet and attach it to the goldenrod copy of the Ambulance Run Sheet. Information will include, but is not limited to: patient name, date of transport, relevant drugs and/or supplies. 6. This restocking program does not apply to the restocking of ambulances that only provide non-emergency services or to the general stocking of an ambulance provider’s inventory. 7. Hospital does not bill any Federal health care program for restocked drugs or supplies. Ambulance providers must notify Hospital if they intend to submit claims for restocked drugs or supplies to any Federal health care program. 8. It is the responsibility of any participant in the ambulance restocking arrangement that bills Federal health care programs for restocked drugs or supplies to comply with all applicable Federal program billing and claims filing rules and regulations. 9. For further information about our restocking program or to obtain a copy of this notice, please contact the Corporate Compliance Department at ###-###-####. Dated: Signed: