To my insurance carrier(s) or other provider of medical benefits:
- I authorize a copy of this enrollment form and agreement to be used in lieu of the original on file at the Louisville Fire Protection District's office.
- I authorize payment of benefits be made directly to the Louisville Fire Protection District for emergency medical/ambulance transport services for eligible family members or myself.
- I authorize and direct reimbursement for emergency medical/ambulance services pursuant to my policy(ies) to be sent directly to the Louisville Fire Protection District.