FIND BETTER PEACE OF MIND

QUESTIONS?
What is Eagle Air Med?
SERVICE AREA MAP
Service area not limited to base locations
Eagle Air Med is a regional air ambulance provider
that transports patients from rural medical facilities to
larger hospitals with specialty care services, 24 hours a
day, 7 days a week. We primarily provide air medical
services in Alamosa, CO; Gallup, NM; Chinle, AZ; and
Kayenta, AZ. Our headquarters is in Blanding, UT.
Montan
a
Why Should I Become an Eagle Air Med Plus
Program Member?
Your membership helps offset the high cost of providing
medical air transport to you, your community, family
and friends. It also helps purchase equipment and
medical supplies for the helicopters and airplanes.
In the event that you or a family member requires a
medically necessary transport from one hospital to
another, or to be transported from an emergency
scene by an AMRG Company, you will not have any
out of pocket charges.
North
Dakota
Wyomin
g
Utah
Arizona
How does this Work?
The Eagle Air Med Plus Program and AMRG family of
transport programs (see service area map) work closely
with local fire departments, ground ambulances,
W
hile none of us ever expect
to need air ambulance
transportation, it is comforting
to know that you and your family are
guaranteed exceptional care, prompt
and dependable service, peace of
mind, and no out-of-pocket expenses
when you are an Eagle Plus member.
Colora
do
New
Mexico
FIND
BETTER PEACE
OF MIND
Michigan
law enforcement agencies, medical facilities, and
physicians, to ensure safe, expedient, and lifesaving
care for our patients.
Hawaii
If another air transport company flew me, will
my membership cover their bill?
Puerto Rico
B
No. Your membership will not cover any charges from
another service.
If I am traveling am I covered?
Yes. If you are transported by any AMRG company,
you are covered by your membership at no additional
cost! deductible and co-pay, leaving members with
no out-of-pocket expenses.
Alaska
866-290-0473
CALL FOR MORE INFORMATION
y becoming a member you
become affiliated with the
largest, most respected, and
most experienced air ambulance
service in Southern Colorado and
the Four Corners area. We have
over 30 years experience and have
transported more than 31,000 patients.
Each patient is cared for by a highly
trained, registered flight nurse and
flight paramedic, and is flown by an
experienced air transport pilot.
DISCLAIMER
By enrolling in the Eagle Air Med membership program, I agree
as follows:
• Membership applies to me, my spouse/partner and
dependent children under the age of 26 who live with us and
are insured, as listed on the application.
• All services covered by this membership must be arranged
through or authorized by Eagle Air Med and must be within
Eagle Air Med’s scope of care.
• If I receive an air medical transport by Eagle Air Med, Air
Medical Resource Group (Eagle Air Med) will bill my insurance
or other responsible third party payer (collectively, “Insurance”).
Eagle Air Med will accept the amount paid by my Insurance
as payment in full for any medically necessary transport. The
membership fee constitutes prepayment for any deductible,
copayment or other out-of-pocket expense not covered by
my insurance, so I will be relieved of any out of pocket expense
following transport. Subject to the foregoing, I acknowledge
that I am responsible for payment for ground ambulance
services rendered to me. Any payment(s) sent to me by my
insurance for a Eagle Air Med air ambulance flight must be
submitted to Eagle Air Med within ten (10) days of receiving
payment.
• In the event I am transported by an Eagle Air Med transport
program, I hereby assign and transfer to Eagle Air Med all
benefits payable by Insurance to or for my benefit, or the benefit
of my spouse or dependents that are named as enrollees on
my membership, for any services rendered.
• Membership covers only medically necessary air medical
transports completed by Guardian Flight, 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.
• I understand that under some circumstances, Eagle Air Med
may not be available to transport me. This may be due to
weather conditions, maintenance, aircraft previously committed
to another transport, FAA restrictions, governmental market
restrictions or other factors. I understand that membership does
not cover the cost of any transport rendered by other air or
ground providers other than Eagle Air Med.
• Membership becomes effective three (3) days after Eagle Air
Med 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 Eagle Air Med Membership Office within five
business days of any change in my Insurance or the Insurance of
any family members enrolled in the Eagle Air Med Membership
Program.
• Neither I, nor the family members named below, are Medicaid
enrollees.
I understand that my Eagle Air Med 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.
A copy of member(s) insurance card must be submitted with
application. If spouse/partner and dependents listed above
have different insurance, submit a copy of their card.
QUESTIONS?
PLUS PROGRAM APPLICATION
You can also fill out an application online at www.eagleairmed .com/membershipapp
Member’s Full Name:
First Birth Date:
Month Mailing Address:
Day Middle If I’m a renewing member, do I have to fill out
the application?
Last
Yes, AMRG companies are legally required to have
a new application yearly. This also ensures AMRG
companies have your most up-to-date information.
Phone:
Year
Number and Street or P. O. Box # City State
Health Insurance: Health Insurance ID #:
Provider’s Phone: Health Insurance Group #:
Family Member’s Name*: Relationship to Primary Member: Insurance Provider:
Zip Code
If I’m on a fixed income, is it wise for me to join
the Eagle Air Med Plus Program?
The Eagle Air Med Plus Program is ideal for anyone on
a fixed income, who might otherwise have to absorb
the portion of the bill not covered by insurance.
Birth Date:
If I am transported by ground ambulance to
the aircraft, will my Eagle Air Med Plus Program
cover the cost of the ground ambulance?
No, the Eagle Air Med Plus Program does not cover
ground ambulance charges unless transported by
Med Star ground ambulance in Gallup, NM.
Is an AMRG company guaranteed to be
available when requested for transport?
Membership Plans with Yearly Rates for Singles and Families* (Check box):
1-Year Single or Family with Insurance: $50
1-Year Single or Family without Insurance: $80
* Family members include spouse and dependents to age 26. If more space is required to include all family members,
continue on an additional piece of paper and attach.
Signature: Date:
Referred by: [ ] Eagle Air Med Employee [ ] Hospital Staff [ ] Event [ ] Other: Mastercard
American Express
Check/Money Order (mail with this application)
Name as It Appears on Card (please print):
Credit Card Account #:
• Aircraft may be dedicated to a prior patient transport
• Weather conditions may prevent flying in your area
• You may be in a location where aircraft cannot land
• You may require ground transport
• You may not be in an area where an AMRG aircraft
is not available
If I am a Medicaid recipient should I purchase
the Plus Program?
No, in fact, the application will ask if you or any family
member is a Medicaid recipient. Medicaid already
completely covers the cost of your transport.
PAYMENT OPTIONS
Visa
AMRG companies make every effort to respond to
requests from our members. We have flight crews and
aircraft on duty and available 24 hours a day, 7 days
a week. However, there are many reasons an AMRG
company aircraft may be unavailable to respond:
Signature of Cardholder:
Expiration Date:
Date:
More Questions? Call a Membership Specialist
at 888-566-4868, go to eagleairmed.com, or
e-mail [email protected].
MAIL APPLICATION AND PAYMENT TO:
AMRG, ATTN: Memberships,
10888 S 300 W, South Jordan UT, 84095