ENROLLMENT FORM

EMS
ENROLLMENT FORM
PLEASE COMPLETE CONTRACT, THEN CALL TO SUBMIT PAYMENT TO CHOCTAW COUNTY AMBULANCE AUTHORITY

580-326-2634
Choctaw County Ambulance Authority
MEMBERSHIP STATUS:

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PLEASE PRINT ALL INFORMATION CLEARLY
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MAILING ADDRESS

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MEMBER INSURANCE INFORMATION
MEDICARE MEDICAID SOONERCARE BENEFICIARIES DO NOT QUALIFY
MEDICAID (SOONERCARE) BENEFICIARIES DO NOT QUALIFY
PRIVATE INSURANCE COMPANY
ID
PRIVATE INSURANCE COMPANY
ID
ADDITIONAL HOUSEHOLD MEMBERS AS DEFINED BY TERMS AND CONDTIONS
NAME
Date

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Date
SS # :
MEDICARE
MEDICAID (SOONERCARE) BENEFICIARIES THEY DO NOT QUALIFY
PRIVATE INSURANCE COMPANY
ID
NAME
Date

MonthDayYear
Date
SS # :
MEDICARE
MEDICAID (SOONERCARE) BENEFICIARIES DO NOT QUALIFY
PRIVATE INSURANCE COMPANY
ID
NAME
SS # :
MEDICARE
MEDICAID (SOONERCARE) BENEFICIARIES DO NOT QUALIFY
PRIVATE INSURANCE COMPANY
ID
BY SIGNING BELOW I AGREE TO ALL THE TERMS AND CONDITONS OF THE CHOCTAW COUNTY AMBULANCE AUTHORITY'S MEMBER PLUS PROGRAMAND CETIFY THAT NO APPLICANTS ARE SOONERCARE BENFICIARIES
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