HomeMy WebLinkAboutPackets - Council Packets (190) APPLICATION FORM
HEAD OF HOUSEHOLD
Name
Address
City, State, Zip PROUDLY SERVING AMBULANCE SERVICE
Day Phone ( ) - THE COMMUNITIES OF MEMBERSHIP PLAN
Date of Birth
Social Security# ORO VALLEY, CATALINA, FOR JUST $75 A YEAR
CERTAIN RESTRICTIONS APPLY
SPOUSE/DOMESTIC PARTNER AND SADDLEBROOKE
Name
Date of Birth
Social Security# ;�� Ili 511 #11
MM _,
OTHER HOUSEHOLD MEMBERS � �7R P.I_WCH l'' lii 11
Name � �
) i
Date of Birth Relation .;,,,� ;_;,�:
F l
Name r� <. .40
c)OLDE,9
... _.................,__
, -
Date of Birth Relation `^�.A. .-�"'' Iii - ii6
.......„ _ 1
..- ;,,,,-.--vpro.—. _____ ...2,
MEMBERSHIP PAYMENT ENCLOSED.PLEASE DO NOT SEND CASH. t
i114 I
Check enclosed visa MasterCard GOLDER RANCH FIRE DISTRICT D
rir-
�� '
Discover American Express
3885 EAST GOLDER RANCH DRIVE n S
TUCSON, ARIZONA 85739 .1* *
I:
Credit Card# OFFICE: (520) 825-9001
Exp.Date WWW.GRFDAZ.GOV '9A N C'?`
Name on Card
Date
FILL OUT,TEAR OFF,AND RETURN WITH YOUR PAYMENT TO: REST EAS I E R
AND ENJOY LIFE WITH PEACE OF MIND
GOLDER RANCH FIRE DISTRICT THAT IS AFFORDABLE
3885 EAST GOLDER RANCH DRIVE APPLY ONLINE AT:WWW.GRMHS.ORG
TUCSON,ARIZONA 85739
Annual Membership Terms
The following are the terms of the Golder Ranch EMS Membership plan(The Plan):
ci 0
N C H FM The Plan is available to all residents of Golder Ranch Fire District(The District)
I__DER P/\
S
MEMBERSHIP
and the family members who live in the resident's household (provided that
they are enrolled in the plan at the time of application)and to individuals with
CALL 911
a regular place of work within the boundaries of The District.The Plan covers
only MEDICALLY NECESSARY*ambulance transports provided by The District to
a hospital.Transports from the hospital to another location are not included in
IFYOU HAVE AN EMERGENCY The Plan.
AND N EED AN AM BU LAN *Medicare guidelines determine medical necessity. A Physician Certification
Vii' ,-> I ,\
C E Statement(PCS)documenting the MEDICAL CONDITION that makes ambulance
transportation a MEDICAL necessity is required for all non-emergency trips and
`yit"FL 4
may be required on emergency trips that are denied by Medicare or other third
party agencies. Pre-authorization must be secured prior to non-emergency
OLDER transports for those patients whose insurance requires such authorization.The
`T3► Remember always call 911 in an emergency, regardless Plan covers only that portion of the cost of transport not covered by a patient's
,. health insurance or other available sources of payment.As a courtesy to The Plan
t ; 6 , of your billing concerns. Our first priority is your health member,The District will submit a claim for payment to the member's insurance
and safety, not cost recovery. Emergency Medical for each ambulance transport.
. to,• 41 1).' '
as._ Services will be provided to all citizens, regardless of their Plan members agree to assist The District in collecting payments from insurance
i providers,including but not limited to promptly providing necessary information
�' financial circumstances. Each ambulance is equipped with and signatures for submission of claims to insuranceproviders and takingother
1*-� keit*' g
"' ��; ste s necessar or reasonabl re uired to facilitate a ment to The District.If the
..4 44 --�'` sophisticated life-savingtechnologythat is critical duringan p y y q p y
p Plan member receives a payment for the ambulance transport directly from their
} emergency,and every ambulance has a paramedic on duty
insurance provider,the member will immediately forward such payment to The
District.Failure to remit payment to The District within five days of receipt will
ma that is trained in Advanced Life Support(ALS). result in the Member being responsible for the full cost of the transport pursuant
to The District's fee schedule in effect at the time of the Member's ambulance
transport.
Golder Ranch Fire District EMS Membership is a way to Simply complete the enclosed application and enrollment
protectyou andyour loved ones from the unexpected The Plan membership will be effective for twelve full months upon receipt of full
p contract form and return it to the address below.Only those payment together with a signed membership agreement.The Membership fee
COSI of emergency ambulance transport. The current is non-refundable and non-transferable.The undersigned member requests that
g Y p household members listed on the form will be covered under payment of authorized benefits be made on my behalf to:
Arizona Department of Health Services regulated cost thelan. Return the form to us with a check,moneyorder or
p Golder Ranch Fire District(3885 E.Golder Ranch Dr. Tucson,AZ 85739
of an emergency ambulance transport in Golder Ranch authorization to charge your Visa or MasterCard account for direct 520-825-5902 fax 520-825-5985
Fire District is well over $1,000.00. Depending on your $75.00. As soon as we receive your signed application and The undersigned member authorizes any holder of medical information or
insurance plan the cost of ambulance transportation payment,you willbe automatically enrolled in GolderRanch documentation about the member to release any information or documentation
pa y
needed to determine these benefits or benefits payable for related services
may not be covered fully.When this occurs (or if you are EMS Membership. Coverage will begin from the date your provided by The District now or in the future.
uninsured) you will be responsible for the remainder of signed contract and payment is received and continue for NOTICE:In the event your check is dishonored or returned for any reason,you
the fees from the ambulance transport.Golder Ranch Fire authorize us to electronically(or by paper draft)re-present the check on your bank
p 12 full months. account for the collection of the amount of the check plus any applicable fees as
District has implemented an EMS Membership Program permitted by law.THE USE OF A CHECK FOR PAYMENT IS YOUR ACCEPTANCE OF
that has been approved by the Arizona Department of THIS AGREEMENT.
Health Services,that offers youprotection from those fees. By signing this form and paying my membership fee I agree to the terms and
conditions listed.
It will cover you and any other household members for Golder Ranch EMS Membership is a pre-paid service program offered by Golder
ambulance transportation to the hospital for just $75.00 Ranch Fire District.At no time will you be denied emergency medical services or
transport based on insurance status or ability to pay.
per household per year.
•
•
HEAD OF HOUSEHOLD
This means that Golder Ranch EMS Membership could
more than pay for itself in one trip alone. The plan is Signature: Date:
6 44
available to all residents of Golder Ranch Fire District and �,, �.��
the family members who live in the resident's household.
*, "''a : SPOUSE/DOMESTIC PARTNER
... "e' ',,,,- -,. ,,,,,t " 3� , „ ; ` .` Signature: Date:
,.,
_,., _ , , g
nce
Golder Ranch EMS Membership will cover ambulance w� 6 i '.,,
transport from anywhere within Golder Ranch Fire District RESIDENTIAL ADDRESS
and covers transport to the nearest appropriate hospital,
not the hospital of choice. If an ambulance responds but f - $:*:-4* ;,,,,,,,.., ‘-
the patient is not transported,there will be no charge. a �.•