# Title 23 — Health and Safety

## Chapter 23-27 — Emergency Medical Services Operations Licenses

### § 23-27-01. License required - Licensing of emergency medical services operations -

Exception - Waiver.
1. The department of health and human services shall license emergency medical
services operations and may designate their service areas. The department shall limit
the issuance of a license for any new emergency medical services operation based on
the needs of the service area. A license for an emergency medical services operation
is transferable upon approval of the department.
2. Emergency medical services may not be advertised, offered, or provided to the public
except by an emergency medical services operator that provides the emergency
medical services through emergency medical services personnel.
3. An emergency medical services operation must be separately licensed for each of the
designated service area of the operation. Under this subsection, an operation may
position vehicles and emergency medical services personnel at more than one
location within the designated service area of an emergency medical services
operation.
4. Notwithstanding subsection 3, an operator of an emergency medical services
operation may operate one or more substation ambulance services operations under a
single license if:
a. The substation ambulance services operation was designated before
December 31, 2024, and remains continuously designated;
b. The headquarters ambulance services operation is not a substation ambulance
services operation of another emergency medical services operation;
c. The substation ambulance services operation area borders the headquarters
ambulance services operation area or borders another substation of the
headquarters ambulance services operation;
d. The headquarters ambulance services operation and the substation ambulance
services operation are dispatched by the same entity; and
e. The operator of the emergency medical services operation pays a license fee for
each of its substation ambulance services operations.
5. The provisions of this chapter do not apply to an operator from another state which is
headquartered at a location outside of this state and transports patients across state
lines, but the operator may not treat patients within this state or pick up patients within
this state for transportation to locations within this state, except as provided by rule.
6. The department of health and human services shall adopt rules for special licenses
and waiver provisions for an operator of an emergency medical services operation
intended for industrial sites not available to the general public.
### § 23-27-02. Definitions.

For the purpose of this chapter, unless the context otherwise requires:
1. "Department" means the department of health and human services.
2. "Emergency medical services" means the prehospital medical stabilization or
transportation, including interfacility transportation, of an individual who is sick, injured,
wounded, or otherwise incapacitated or helpless, or in a real or perceived acute
medical condition, by a person that holds oneself out to the public as being in that
service or that regularly provides that service. The term includes:
a. Assessing, stabilizing, and treating life-threatening and non-life-threatening
medical conditions; or
b. Transporting a patient who is in a real or perceived acute medical condition to a
hospital emergency room or other appropriate medical destination.
3. "Emergency medical services operation" means an entity licensed to offer and provide
emergency medical services by emergency medical services personnel with physician
oversight. The term includes basic life support ambulance services, advanced life

support ambulance services, air ambulance services, and quick response unit
services.
4. "Emergency medical services personnel" means individuals who provide emergency
medical services for emergency medical services operations. The term includes
emergency medical services professionals, drivers, and department-certified
emergency medical services providers, such as cardiopulmonary resuscitation drivers
and first responders.
5. "Emergency medical services professional" means an individual licensed by the
department under this chapter.
6. "Substation ambulance services" means an ambulance station that has its own service
area designated by the department and is not individually licensed as an emergency
medical services operation.
### § 23-27-03. License fees.

The fee for an emergency medical services operation license to operate an emergency
medical services operation or a substation ambulance services operation must be set at a sum
of not more than twenty-five dollars annually, as may be required to defray the costs of
administration of the licensing program. This operation license fee does not apply to licensure or
certification of emergency medical services personnel. All license fees must be paid to the
department of health and human services and deposited with the state treasurer and credited to
the state general fund.
### § 23-27-04. Standards for operators.

1. An emergency medical services operation may not operate unless licensed under this
chapter. The department shall adopt rules for standards for operators which must
include:
a. Time when operator's services must be available;
b. Requirements for services to ensure a reliable response to 911 and emergent
interfacility transports, while providing nonemergent services;
c. Type of motor vehicle operator's license needed for drivers of ground vehicles;
d. Training standards for personnel;
e. Equipment and ground vehicle standards;
f. Annual license fees;
g. Number of personnel required for each run;
h. The scope of practice for uncertified drivers, certified personnel, and emergency
medical services professionals;
i. Performance standards, which may include response time standards; and
j. Other requirements as necessary to carry out the requirements of this chapter.
2. An officer, employee, or agent of any prehospital emergency medical services
operation may refuse to transport an individual for which transport is not medically
necessary and may recommend an alternative course of action to that individual if the
prehospital emergency medical service has developed protocols to refuse transport of
an individual.
### § 23-27-04.1. Emergency care or services rendered by officers, employees, or agents of

emergency medical services operations - Physician medical direction.
1. An officer, employee, or agent of an emergency medical services operation and a
physician licensed in this state who provides medical direction to an emergency
medical services operation, who is a volunteer, who in good faith renders emergency
care, services, or medical direction, is not liable to the recipient of the emergency care,
services, or medical direction for any civil damages resulting from any acts or
omissions by the person in rendering the emergency care, services, or medical
direction provided the person is properly trained according to law.
2. For the purpose of this section, "volunteer" means an individual who receives no
compensation or who is paid expenses, reasonable benefits, nominal fees, or a

combination of expenses, reasonable benefits, and nominal fees to perform the
services for which the individual volunteered, provided that the fees do not exceed ten
thousand dollars in any calendar year.
3. For a volunteer physician providing medical overview to an emergency medical
services operation and the operation's personnel, the ten thousand dollar maximum
fees amount is calculated separately for each emergency medical services operation
for which the physician volunteered medical overview. This section does not relieve a
person from liability for damages resulting from the intoxication, willful misconduct, or
gross negligence of the person rendering the emergency care or services.
4. An officer, employee, or agent of any emergency medical services operation and a
physician licensed in this state who provides medical direction to any emergency
medical services operation who in good faith does not render emergency care,
service, or medical direction to an individual based on a determination that transport of
that individual to a hospital is not medically necessary is not liable to that individual for
damages unless the damages resulted from intoxication, willful misconduct, or gross
negligence.
### § 23-27-04.2. Emergency medical services - State assistance.

The department of health and human services shall assist in the training of emergency
medical services personnel of certain emergency medical services operations as determined by
the department and financially shall assist certain emergency medical services operations as
determined by the department. Assistance provided under this section must be within the limits
of legislative appropriation. The department shall adopt criteria for eligibility for assistance in the
training of emergency medical services personnel of various types of emergency medical
services operations. The department may establish minimum and maximum amounts of
financial assistance to be provided to an emergency medical services operation under this
section. If applications for financial assistance exceed the amount of allocated and available
funds, the department may prorate the funds among the applicants in accordance with criteria
adopted by the department. No more than one-half of the funds appropriated by the legislative
assembly each biennium and allocated for training assistance may be distributed in the first year
of the biennium. For emergency medical service operations subject to section 23-27-07, after
June 30, 2025, financial assistance provided by this section must be distributed to the political
subdivision having ownership of the licensed ambulance service or the political subdivision
responsible for the emergency medical service program for the service area.
### § 23-27-04.3. Emergency medical services personnel training, testing, certification,

licensure, and quality review - Penalty.
1. The department shall adopt rules prescribing minimum training, testing, certification,
licensure, and quality review standards for emergency medical services personnel,
including community emergency medical services personnel, instructors, and training
institutions.
2. Rules adopted must include a definition of minimum applicable standards, a definition
of emergency medical services personnel, provide for a mechanism for certifying or
licensing persons who have met the required standards, provide a mechanism to
review and improve the quality of care rendered by emergency medical services
personnel, and define minimum standards for emergency medical services training
institutions.
3. Rules adopted must allow emergency medical services instructors to provide direct,
entry-level certification training for the levels of emergency medical responder and
emergency medical technician, under the oversight of the department and without the
requirements of an emergency medical services training institute.
4. Licensing as an emergency medical services training institution is optional.
5. It is a class B misdemeanor for an individual to willfully misrepresent that individual's
certification or licensing status as emergency medical services personnel.
6. Quality review and improvement information, data, records, and proceedings are not
subject to subpoena or discovery or introduction into evidence in any civil action.

### § 23-27-04.4. Supervision of emergency medical services professionals - Scope of

practice.
Emergency medical services professionals who are employed by a hospital may provide
patient care within a scope of practice established by the department. Under this section, these
emergency medical services professionals must be supervised by a hospital designated
physician, physician assistant, advanced practice registered nurse, or registered nurse.
### § 23-27-04.5. Quick response unit service pilot program.

Expired under S.L. 2001, ch. 246, § 14.
### § 23-27-04.6. Quick response units.

Department licensure as a quick response unit is not optional. The department's standards
under section 23-27-04 for the time when a quick response unit's services must be available
may not require twenty-four hour availability.
### § 23-27-04.7. County reporting - Use of property tax levies.

The board of county commissioners of every county in this state shall conduct an annual
review of the emergency medical services coverage within that county and shall submit an
annual report in a format approved by the department of health and human services. A taxing
district that levies a special emergency medical services or ambulance service levy shall
allocate all of the special tax levy revenue collected in a particular township to the ambulance
service that serves the largest area within that township.
### § 23-27-04.8. Emergency medical services operation communications.

The department may regulate the primary communications methods and protocols for
emergency medical services operations while permitting secondary communications through
other devices, including cell phones. The regulations must be consistent with the protocols
established by the department of emergency services.
### § 23-27-04.9. Administration of vaccinations - Laboratory testing.

1. A licensed or certified emergency medical services personnel working for a hospital or
an emergency medical services operation may administer a vaccine to an individual
who is at least eighteen years of age if:
a. The physician providing oversight for the emergency medical services operation
or the hospital medical director has established protocols that meet department
standards that may be based on the advisory committee on immunization
practices of the federal centers for disease control and prevention; and
b. The emergency medical services personnel has satisfactorily completed a
department-approved course on administering vaccines.
2. If a hospital or emergency medical services operation allows the administration of
vaccines under this section, the hospital or emergency medical services operation
shall maintain records documenting the emergency medical services personnel's
completion of the training required under subsection 1. These records are subject to
review by the department.
3. Licensed or certified emergency medical services personnel may perform laboratory
testing authorized by rule adopted by the department.
### § 23-27-04.10. Air ambulance services.

1. The department shall create and maintain a primary call list and a secondary call list of
air ambulance service providers operating in this state.
2. To qualify to be listed on the primary call list, an air ambulance service provider shall
submit to the department attested documentation indicating the air ambulance service
provider is a participating provider of the health insurance carriers in the state which
collectively hold at least seventy-five percent of the health insurance coverage in the
state as determined by annual market share reports.

3. The department shall provide the primary call list and the secondary call list for air
ambulance service providers operating in this state to all emergency medical services
personnel, each hospital licensed under chapter 23-16, each 911 coordinator in this
state, and each public safety answering point operating in this state.
4. The department shall establish air ambulance service response zones for rotary wing
aircraft which are based on response times and patient health and safety.
a. Upon receipt of a request for air ambulance services, emergency medical
services personnel, a hospital licensed under chapter 23-16, or a public safety
answering point operating in this state, shall make a reasonable effort to inform
the requesting party of the estimated response time for the requested air
transport versus the ground transport for that designated response zone. If at any
point during the request for air ambulance services the requester withdraws the
request, the receiving party is not required to complete that call for air ambulance
services.
b. If emergency medical services personnel, a hospital licensed under
chapter 23-16, or a public safety answering point operating in this state receives
a request from emergency medical services personnel for air ambulance
services, the recipient of the request shall comply with the call priority under this
subdivision in responding to the request.
(1) First, the recipient of the request shall call an air ambulance service provider
listed on the primary call list which is within the designated response zone.
(2) Second, if each of the air ambulance service providers listed on the primary
list is not available or is not able and willing to respond to the call, the
recipient of the request shall notify the requester of this fact and shall call an
air ambulance provider listed on the secondary call list within the designated
response zone.
(3) Third, if each of the air ambulance service providers listed on the secondary
list is not available or is not able and willing to respond to the call, the
recipient of the request shall notify the requester of this fact and shall inform
the requester of primary and secondary air ambulance service provider
options outside the designated response zone.
5. Upon request of the department, a potential patient, or a potential patient's legal
guardian, an air ambulance service provider shall provide that provider's fee schedule,
including the base rate, per loaded mile rate, and any usual and customary charges.
a. The department shall compile and distribute this fee information to each hospital
licensed under chapter 23-16, each hospital emergency department in the state,
each physician the department determines is likely to generate an air ambulance
transport, each emergency medical services operation, each emergency medical
services professional, each emergency medical services personnel, each public
safety answering point in this state, and each 911 coordinator in this state.
b. Before a hospital refers a patient to an air ambulance service provider, the
hospital shall make a reasonable effort to inform the patient or the patient's legal
guardian of the fees for the air ambulance service providers licensed under this
chapter, for the purpose of allowing the patient or legal guardian to make an
informed decision on choosing an air ambulance service provider. A hospital is
exempt from complying with this subdivision if the hospital determines
compliance might jeopardize the health or safety of the patient.
6. The department of health and human services shall adopt rules establishing air
ambulance service provider requirements that must address transport plans, including
auto launch protocol and auto launch cancellation protocol; transporting to the nearest
appropriate medical facility; medical necessity; and informed consent. As necessary,
the department of health and human services shall adopt rules relating to quality of
care standards and other appropriate requirements regarding air ambulance service
providers.

### § 23-27-05. Penalty.

Any person violating the provisions of this chapter is guilty of an infraction.
### § 23-27-06. Criminal history record check.

The department may require an applicant for emergency medical services personnel
licensure to submit to a statewide and nationwide criminal history record check. The nationwide
criminal history record check must be conducted in the manner provided by section 12-60-24.
All costs associated with the criminal history record check are the responsibility of the applicant.
### § 23-27-07. Required formation of rural ambulance service district - Organizational

meeting - Exemption - Eligibility for relicensure.
1. Emergency medical service operations licensed under this chapter as a basic life
support or advanced life support ambulance service for which a territory has been
assigned pursuant to this chapter does not include a city with a population greater than
six thousand five hundred according to the 2020 census data published by the United
States census bureau, and is not otherwise exempted, must conduct a rural
ambulance service district organizational meeting pursuant to the procedure in section
be deemed organized and operating under the provisions of chapter 11-28.3.
2. The following licensed ambulance services are exempt from this section:
a. Licensed ambulance services that are county owned.
b. Licensed ambulance services that are city owned.
c. Licensed ambulance services that are part of a joint powers agreement with a city
or county-owned ambulance.
d. Licensed ambulance services owned by tribal or federal government.
e. Existing rural ambulance service districts organized pursuant to chapter 11-28.3.
3. Ambulance services not in compliance with this section may not be eligible for
relicensure under this chapter.
### § 23-27-08. Balance billing prohibited - Enforcement.

1. For purposes of this section, "ambulance service provider" means a service entity
licensed under chapter 23-27 as a basic life support or advanced life support
ambulance service. The term does not include an air ambulance provider.
2. An ambulance service provider may not collect or bill more than the covered
individual's deductible, coinsurance, copayment, or other cost-sharing amount the
covered individual would be responsible for if services were provided by a participating
ambulance service provider.
