program - Eagle Air Med

MEMBERSHIP APPLICATION
NEW
RENEWAL
PRIMARY MEMBER INFORMATION
Full Name
Address
City
State
Zip Code
D.O.B.
Telephone
Email
FAMILY MEMBER INFORMATION
NAME
RELATIONSHIP
D.O.B.
PLUS PROGRAM BENEFITS
• There are no out-of-pocket expense for any
emergent or medically necessary flights you
or your dependents may need during the term
of the agreement
• The Plus Program membership covers you and
your dependents for a low annual fee
• The Plus Program provides you with coverage
throughout AMRG’s extensive network (see
service area map)
• The Plus Program membership provides you
with peace-of-mind and reassurance that you will
not be burdened by expensive air medical bills
KEY MEMBERSHIP TERMS
•
I understand that my Plus Program membership is not an insurance
product. I certify that I am the individual applying for membership and
am the legal representative of my spouse and dependent children listed
below, and am duly authorized by them to execute this application and
accept its terms and conditions on their behalf.
•
Neither I, nor the family members named below, are Medicaid enrollees.
•
Membership covers only medically necessary air medical transports
completed by Eagle Air Med, or another AMRG company, and only those
transports to the closest appropriate hospital. Medical necessity is
determined by my insurance based on information from the attending
physician. I am responsible for the cost of any transports that are
determined not to be medically necessary by my insurance.
•
The Eagle Air Med Plus Program only applies to emergent transports and
does not apply to any scheduled transport or non-emergent transport.
•
Membership becomes effective three (3) days after EAM’s receipt of a
completed application, accompanied by a payment of the membership
fee. There is no waiting period for membership renewal.
•
I agree to notify AMRG Membership Office within five business days of
any change in my Insurance or the Insurance of any family members
enrolled in the Plus Program.
MEMBERSHIPPROGRAM
By becoming a member of the Plus Program, you agree to the
key membership terms listed above. For a complete list of
membership terms, please visit us at www.amrg.com/membership
MEMBERSHIP PLANS
With Insurance
1 year: $50
2 year: $90
3 year: $130
Without Insurance
1 year: $80
2 year: $120
3 year: $160
PAYMENT METHOD
MASTERCARD
CHECK
VISA
CREDIT CARD
AMEX
CONFIDENT
Credit Card Number
Card Expires
Verification Number*
*Please enter the Credit Card Verification Number on your credit card. For MasterCard and
Visa this is the last three numbers printed on the back of your card. For American Express
it is a four digit number printed on the front of your card.
SAFE
PROGRAM
Full Name as shown on card
SIGNATURE
SECURE
REFERRED BY
PLEASE MAKE CHECKS AVAILABLE TO EAGLE AIR MED:
Return Order Form to:
10888 S 300 W, SOUTH JORDAN, UT., 84095
PROTECT WHAT MATTERS MOST!
EAGLE AIR MED
Eagle Air Med
10888 South 300 West
South Jordan, UT 84095
www.eagleairmed.com
CONTACT US
866-290-0473
PLUS PROGRAM ADVANTAGE
The need for emergent air medical transportation can
happen to anyone at anytime and typically without
warning. If you or a family member become ill or is involved in an accident, EMS or healthcare providers may
determine that an air ambulance flight is in your best
interest. Fortunately, the Eagle Air Med Plus Program
membership protects you, and your family from having
any out-of-pocket expenses for a minimal annual fee.
Air medical transportation is expensive and health
insurance may not cover all of the costs. As a member,
you do not need to worry about those additional costs.
We will work with your insurance provider for their
portion of the bill and the rest is completely covered
by your membership!
If you do not have insurance, we have a membership
plan for you as well! For just $80 per year, you can also
receive the same benefits described above!
PROVIDING
FINANCIAL
PEACE OF
MIND.
OUTSTANDING MEDICAL CARE
With aircraft strategically located, Eagle Air Med is
prepared to quickly respond with the highest level
of care to any and all transport needs within our service area in Kayenta (AZ), Chinle (AZ), Del Norte (CO),
Alamosa (CO), and Gallup (NM).
Eagle Air Med staff are the most professional and experienced individuals in the industry. We operate state of
the art, cutting edge equipment. All of which allows us
to provide the best care available.
EXTENSIVE COVERAGE
Sidney
MT
Through strategic deployment of experienced staff,
fully-equipped aircraft, and management expertise,
Eagle Air Med flight crews and aircraft are on duty and
available 24 hours a day, 7 days a week.
Devils Lake
ND
Grand Forks
Dickinson
Gillette
Lander
Williston
Riverton
SD
MN
Houghton
Iron Mountain
Escanaba
WI
MI
WY
Ogden
Payson
Price
UT
CO
Del Norte
Alamosa
Kayenta
Chinle
Fort Defiance
AZ
Gallup
NM
When you become a member, your membership extends to all AMRG compaines nationwide. This means
if you are transported by any AMRG company, you are
covered by your membership at no additional cost!
AK
OFFSET THE
HIGH COST
OF MEDICAL
BILLS!
PR
SERVICE AREA MAP
- WITHIN 1 HOUR RESPONSE TIME
- BASE LOCATIONS
“We understand that air ambulance service is a
necessity and we do not take the public’s trust
lightly. Eagle Air Med is proud to maintain high
standards in all areas of operation including
protecting our patients with the Plus Program.”
Sincerely,
Joseph Hunt
President, Eagle Air Med