LifeCare Ambulance Form

With MemberCare From
lifeCare Ambulance
It's Just $38 A Year.
How MemberCare works:
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LifeCare will bill Medicare or your insurance company for any medically necessary ambulance trips to the
closest, appropriate medical facility. Any co-pays or deductibles your insurer requires you to pay is
covered by MemberCare.
Your membership becomes effective 3 days after receipt of payment and a signed membership agreement
If the insurance company sends you the check, you must forward the check to LifeCare Ambulance but you
are not responsible for any balance remaining
Wheelchair van transportation is offered at a discounted rate. Wheelchair transportation is usually not
covered by your insurance.
You will receive a membership card.
FOR MORE INFORMATION. CAll 269-565-4148
or 1-800-261-1161
Visit our website www.lilecareems.org
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MemberCare Membership Contract
Terms and Conditions
I understand that the $38 annual fee for MemberCare covers out-of-pocket expense for services covered by my insurance, including
coinsurance and deductibles, of LifeCare Ambulance Service bills for medically necessary ambulance transportation to or from our local
hospitals. I understand that the membership is effective three (3) days after receipt of full payment and a signed membership agreement.
I understand that MemberCare is not an insurance or health-maintenance organization (HMO) and that LifeCare will bill and receive
claim payments from my insurer or third-party agency {an HMO, Medicare, Blue Cross, etc.}. To facilitate processing of authorized claims,
I request that payment of authorized insurance benefits be made on my behalf to LifeCare Ambulance or myself, for any ambulance
service and supplies furnished by LifeCare Ambulance. I authorize holder of medical information concerning me, to release to the Centers
for Medicare and Medicaid Services and it's carriers or other insurance companies, as well as to LifeCare Ambulance, any information
needed to process all claims now and in the future and to determine these benefits or the benefits payable for related services. I consent
to the use and disclosure by LifeCare Ambulance Service of my protected health information (PHI) for purposes of treatment, payment and
health care operations, for reporting to local medical control authorities and, and for the purposes of business associates in support of all of
the foregoing. This authorization remains in effect until I revoke it in writing.
I permit a copy of this authorization to be used in place of the original. If the insurance company sends a check to me for services
rendered by LifeCare Ambulance Service, I agree to promptly forward that check to LifeCare Ambulance Service. LifeCare Ambulance
Service reserves the right to require a physician certification of medical necessity for all non-emergency transports by ambulance.
I understand that medically necessary ambulance trips that are not covered by insurance, are rendered at a 20% discount from
regular rates per trip, and that I am responsible for payment. I understand that Ambu-Van services are offered at a reduced rate.
I understand that my MembershipCare membership fee covers not only me, but my immediate family members (spouse and any
children) living with me who I declare as dependants on this year's federal income tax form.
I understand that my membership covers ground services provided by LifeCare Ambulance Service, within its service area in Cass County,
plus westem Calhoun County, all of Branch County, southern Barry County, Bellevue Township and Village, northeastern Kalamazoo County,
and northeastern St. Joseph County, to or from local hospitals.
The membership agreement must be signed by the insurance policyholder or aumorized person. I understand LifeCare Ambulance
Service reserves the right to reject or revoke membership benefits if it has evidence of abuse of this program. I understand that this
membership is non-transferable and non-refundable. I affirm that I have read and agreed to the terms as described above.
THIS CONTRACT EXPIRES ONE YEAR FROM ENROLLMENT
Signature.
Date
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Spouse's Signature
Date
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IIfI&~FECARE.
AMBULANCE SERVICE
MemberCare Benefits:
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No out-of-pocket expense for medically necessary ambulance service including deductibles and co-pays
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Only $38 per year covers you and your immediate family members (spouse and any children) who are your
legal dependants
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Medically necessary ambulance trips that are not covered by insurance, are rendered at a 20% discount from
regular rates
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Covers ground services provided by LifeCare Ambulance Service, within its service area in Cass County,plus western
Calhoun County, all of Branch County, southern Barry County, Bellevue Township and Village, northeastern
Kalamazoo County, and northeastern St. Joseph County, to or from local hospitals
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Peaceof mind - you never know when an emergency may happen to you or your family
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For all provisions of your MemberCare benefit,
please see the reverse side of this application
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MemberCare Application -lifeCare Anlbulance Service
Member Number
MEMBERSHIP FEE - $38
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FOR OFFICE
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NAME
DATE OF BIRTH
ADDRESS
SOCIAL SECURITY #
APT/LOT #
CITY
STATE
ZIP CODE
PHONE (
-
(USE ONLY)
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)
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E-MAIL,
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LIST FULL NAME OF EACH LEGAL DEPENDENT, BIRTH DATE, AND RELATIONSHIP TO YOU WHO LIVES AT THE ABOVE ADDRESS AND
WILL BE INCLUDED ON THIS MEMBERSHIP. (IF ADDITIONAL SPACE IS REQUIRED, ATTACH SEPARATE SHEET)
NAME
DATE OF BIRTH
RELATIONSHIP
SOCIAL SECURITY NUMBER
-------YOUR PRIMARY INSURANCE
POLICY/CONTRACT # ~
GROUP #
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YOUR SECONDARY INSURANCE
POLICY/CONTRACT #
GROUP #
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SPOUSE'S PRIMARY INSURANCE
POLICY/CONTRACT # '
GROUP # ----
SPOUSE'S SECONDARY INSURANCE
SEND COMPLETED APPLICATION FORM
AND CHECK OR MONEY ORDER FOR $38
PAYABLE TO:
POLICY/CONTRACT #
LlFECARE AMBULANCE
P.O, BOX 116
:J MasterCard
Card#
CASSOPOLIS,
:J Visa
Card#
MI 49031
GROUP #
_
METHOD OF PAYMENT
:J Check
:J Money Order
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Exp. Date
Exp. Date
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