1. No person, either as owner, agent or otherwise, shall furnish, operate, conduct, maintain, advertise, or otherwise be engaged in or profess to be engaged in the business or service of the transportation of patients by ambulance in the air, upon the streets, alleys, or any public way or place of the state of Missouri unless such person holds a currently valid license from the department for an ambulance service issued pursuant to the provisions of sections 190.001 to 190.245.

2. No ground ambulance shall be operated for ambulance purposes, and no individual shall drive, attend or permit it to be operated for such purposes in the state of Missouri unless the ground ambulance is under the immediate supervision and direction of a person who is holding a currently valid Missouri license as an emergency medical technician. Nothing in this section shall be construed to mean that a duly registered nurse, a duly licensed physician, or a duly licensed physician assistant be required to hold an emergency medical technician’s license. When a physician assistant is in attendance with a patient on an ambulance, the physician assistant shall be exempt from any mileage limitations in any collaborative practice arrangement prescribed under law. Each ambulance service is responsible for assuring that any person driving its ambulance is competent in emergency vehicle operations and has a safe driving record. Each ground ambulance shall be staffed with at least two licensed individuals when transporting a patient, except as provided in section 190.094. In emergency situations which require additional medical personnel to assist the patient during transportation, an emergency medical responder, firefighter, or law enforcement personnel with a valid driver’s license and prior experience with driving emergency vehicles may drive the ground ambulance provided the ground ambulance service stipulates to this practice in operational policies.

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3. No license shall be required for an ambulance service, or for the attendant of an ambulance, which:

(1) Is rendering assistance in the case of an emergency, major catastrophe or any other unforeseen event or series of events which jeopardizes the ability of the local ambulance service to promptly respond to emergencies; or

(2) Is operated from a location or headquarters outside of Missouri in order to transport patients who are picked up beyond the limits of Missouri to locations within or outside of Missouri, but no such outside ambulance shall be used to pick up patients within Missouri for transportation to locations within Missouri, except as provided in subdivision (1) of this subsection.

4. The issuance of a license pursuant to the provisions of sections 190.001 to 190.245 shall not be construed so as to authorize any person to provide ambulance services or to operate any ambulances without a franchise in any city not within a county or in a political subdivision in any county with a population of over nine hundred thousand inhabitants, or a franchise, contract or mutual-aid agreement in any other political subdivision which has enacted an ordinance making it unlawful to do so.

5. Sections 190.001 to 190.245 shall not preclude the adoption of any law, ordinance or regulation not in conflict with such sections by any city not within a county, or at least as strict as such sections by any county, municipality or political subdivision except that no such regulations or ordinances shall be adopted by a political subdivision in a county with a population of over nine hundred thousand inhabitants except by the county’s governing body.

6. In a county with a population of over nine hundred thousand inhabitants, the governing body of the county shall set the standards for all ambulance services which shall comply with subsection 5 of this section. All such ambulance services must be licensed by the department. The governing body of such county shall not prohibit a licensed ambulance service from operating in the county, as long as the ambulance service meets county standards.

7. An ambulance service or vehicle when operated for the purpose of transporting persons who are sick, injured, or otherwise incapacitated shall not be treated as a common or contract carrier under the jurisdiction of the Missouri division of motor carrier and railroad safety.

8. Sections 190.001 to 190.245 shall not apply to, nor be construed to include, any motor vehicle used by an employer for the transportation of such employer’s employees whose illness or injury occurs on private property, and not on a public highway or property, nor to any person operating such a motor vehicle.

9. A political subdivision that is authorized to operate a licensed ambulance service may establish, operate, maintain and manage its ambulance service, and select and contract with a licensed ambulance service. Any political subdivision may contract with a licensed ambulance service.

10. Except as provided in subsections 5 and 6, nothing in section 67.300, or subsection 2 of section 190.109, shall be construed to authorize any municipality or county which is located within an ambulance district or a fire protection district that is authorized to provide ambulance service to promulgate laws, ordinances or regulations related to the provision of ambulance services. This provision shall not apply to any municipality or county which operates an ambulance service established prior to August 28, 1998.

11. Nothing in section 67.300 or subsection 2 of section 190.109 shall be construed to authorize any municipality or county which is located within an ambulance district or a fire protection district that is authorized to provide ambulance service to operate an ambulance service without a franchise in an ambulance district or a fire protection district that is authorized to provide ambulance service which has enacted an ordinance making it unlawful to do so. This provision shall not apply to any municipality or county which operates an ambulance service established prior to August 28, 1998.

12. No provider of ambulance service within the state of Missouri which is licensed by the department to provide such service shall discriminate regarding treatment or transportation of emergency patients on the basis of race, sex, age, color, religion, sexual preference, national origin, ancestry, handicap, medical condition or ability to pay.

13. No provision of this section, other than subsections 5, 6, 10 and 11 of this section, is intended to limit or supersede the powers given to ambulance districts pursuant to this chapter or to fire protection districts pursuant to chapter 321, or to counties, cities, towns and villages pursuant to chapter 67.

14. Upon the sale or transfer of any ground ambulance service ownership, the owner of such service shall notify the department of the change in ownership within thirty days of such sale or transfer. After receipt of such notice, the department shall conduct an inspection of the ambulance service to verify compliance with the licensure standards of sections 190.001 to 190.245.