Non-Committed Standby EMS Event Form

[Evaalyn Ashryver]

San Andres Medical Services
EMS Non-Committed Standby Services Agreement

The San Andres Medical Services (SAMS) understands the importance of providing EMS during special events or community programs. The Non-Committed Standby Agreement must be utilized in order to arrange any special EMS coverage.
In order for any organization or governmental entity to request special standby services from SAMS, the agreement must be requested, completed, signed and returned to SAMS at least seven (7) days prior to start of any single occurring special event.
Although SAMS will make every effort to provide the level of service requested, no specific coverage can be guaranteed due to the nature of EMS and the fact that the first priority of EMS is to respond to 911 calls. Please read the agreement carefully for details.

To complete the process of requesting Non-Committed Standby Services from San Andres Medical Services, please complete the agreement before the applicable deadlines.

San Andres Medical Services Non-Committed EMS Standby Services Agreement

A Non-Committed Standby is when a customer requests a paramedic ambulance crew to cover an event and standby for emergencies, but the ambulance is NOT committed to the event. SAMS will assign a crew to the general geographical area in which the event is occurring when one is available. In the event of a request for an ambulance in this area, or should the Emergency Medical System become very busy, the crew will leave your standby event. A Non-Committed standby does not guarantee a paramedic ambulance crew at your event. There is no charge for a Non-Committed Standby and all patients transported are billed the normal established transport rates. For any questions, please contact either Director Evaalyn Ashryver {227-5371}

SAMS is willing to provide such services under the terms set forth;

1. San Andres Medical Services agrees to provide Non-Committed EMS Standby Services to the SERVICE USER. Non-Committed Service, meaning an EMS will attend the service but is not required to stay at the event if a 911 call is placed.
2. SAMS agrees to provide BLS/ALS emergency medical services to the SERVICE USER for the dates, times, and locations specified in the form.
3. The first priority of EMS is to respond to 911 calls. EMS will leave the Event if 911 calls are placed but will return to the Event once they are finished with the call.
4. Hourly charges for this service begin from the time the crew arrives at the designated area until it is released from the Event , with a two-hour minimum charge per EMS unit attached to the Event.
a. BLS rate/ how many ems attached
b. ALS rate/ how many ems attached
5. Upon completion of services, SAMS will bill the Service User for all costs associated with this agreement and SERVICE USER agrees to pay all fees within 1 hour after the EVENT has ended.
6. SAMS reserves the right to refuse any Non-Committed Standby Agreement submitted by SERVICE USER less than seven (7) days prior to the start time of requested Non-Committed Standby services event.
7. This agreement may be canceled by either party by giving a 24- hours advance notice.
8. Nothing herein shall be construed to create a higher standard of care on the part of EMS than generally recognized under the LAWS of San Andres Medical Services. SAMS crew may operate under written protocols and procedures specifically approved by the SAMS Directors.
9. The charges provided to herein reflect only those charges associated with making EMS more readily available to the SERVICE USER.

Non-Committed Standby Services (NCSS) Form

Name/Title of Event:
Event Occurrence 1
Date: (MM/DD/YYYY)
Start Time: (PST)
End Time: (PST)
Location:

Event Occurrence 2 (if applicable)
Date: (MM/DD/YYYY)
Start Time: (PST)
End Time: (PST)
Location:

(If request is for more than 2 event occurrences attach additional details to agreement)

Organization Name:
Primary Contact Person's Name:
Phone Number:
Email Address/ Discord name:

Service User Signature: