I apply for membership with Firelands Ambulance Service for my family and me as defined ad listed on my application. Fir my membership, I enclose the membership fee and the assignment of rights as explained below. I understand that if Firelands Ambulance Service Accepts my application, I will comply with the following terms of the membership contract.
Household members are defined as: myself, my spouse, mu unmarried children and/or my spouse's children who are dependents and live at our address.
Membership applies to emergency ambulance services to a medical facility within the service are of Firelands Ambulance Service.
Payment of the membership fee and the assignment of rights allows Firelands Ambulance Service to make claims for payment against the insurer(s) or medical benefits provider(s) of members having ambulance service coverage.
I assign to Firelands Ambulance Service all my rights and benefits for ambulance services coverage under any and all of my medical insurance policies or other medical benefits contract(s). I also assign to Firelands Ambulance Service all rights I may have under any laws which require timely payment by my insurer. The benefits assigned include all benefits payable under my primary insurance or other medical benefits contract(s) and those due under any supplemental insurance policy, plan or contract. I authorize and direct my insurer(s) or other medical benefits provider(s) to pay directly to Firelands Ambulance Service all sums due under my policies for services by Firelands Ambulance Service.
For services provided by Firelands Ambulance Service, I assign to Firelands Ambulance Service what-ever rights I may have or may get in the future to obtain payment from third persons for those services. I also subrogate Firelands Ambulance Service to whatever claims I may have or other medical benefits provider(s) of the maximum amount due under my policy or plan and controlling law for Firelands Ambulance Service's customary charges, Firelands Ambulance Service will release me from responsibility to pay any remaining amounts due.
The membership program takes effect upon receipt of your payment and application to our office and will be effective for one year. The membership fee fir individuals or family membership is Fifty Dollars ($50.00) per year. Each year, members(s) will receive notice of the annual fee before the renewal of the agreement. Fees and terms of this Agreement may be changed from time to time by Firelands Ambulance Service.