Formas Vuelo

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Reply to Email:
example@example.com

Introductory Information

This section is used to create a record of authorized persons in association with this client claim.
Today's Date:*

MonthDayYear
Date
Who is filling out this form?*

PatientAuthorized Representative On Patient's behalf
Relationship to Patient:*

Identification Information: Patient

Please provide all requested information pertaining to the patient in full.This ensures we have accurate and complete records to support proper care and documentation.
Patient Name:*

First NameLast Name
Patient Date of Birth:*

MonthDayYear
Date
Patient Phone:*
Please enter a valid phone number.
Patient Email:*
example@example.com
Patient Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient / Authorized Representative's Signature:*

Clear

Identification Information: Authorized Rep or Patient

Please provide the required contact information for the individual completing this form.
Who should fill out this section?
- If you are an Authorized Representative (someone other than the patient completing this form on the patient's behalf), please provide your identification information below—this is to ensure accurate and complete documentation.
- If the Patient is completing this form themselves, the section below is still required—even if the same information was already provided earlier—this is to ensure accurate and complete documentation.
Name (Person Completing this Form):*

First NameLast Name
Date of Birth (Person Completing this Form):*

MonthDayYear
Date
Phone Number (Person Completing this Form):*
Please enter a valid phone number.
Email (Person Completing this Form):*
example@example.com
Home Address (Person Completing this Form):*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Signature (Person Completing this Form):*

Clear

ASSIGNMENT OF BENEFITS

IN ACCORDANCE WITH TITLE 29 U.S.C sec. 1132(a)(1)(B)
Patients's Name: {patientName}
Patients's Date of Birth: {patientDate}
Health Plan Member / Insured Name:*

First NameLast Name
Insurance Provider:*
Insured ID Number:*
I, {nameperson}, the above-named member, or authorized person signing on behalf of Patient, agree that payment for the services provided by 24-7 AirEvac, its employees, contractors and agents, are due at the time of service at the rates and charges set forth in the Medical Transport Agreement. In the event that I, or the Patient, or any other representative, trustee, executor, heir or assignee, is entitled to benefits of any type arising out of any policy of insurance or health benefit plan insuring the Patient or any other party liable to me or the Patient, those benefits are hereby irrevocably assigned to 24-7 AirEvac for the application against the charges for 24-7 AirEvac services. Except as otherwise expressly agreed in writing, I shall remain responsible for any and all charges to be paid by the insurance company or other third-party payer and /or not covered by this assignment. Full cooperation shall be provided to assist 24-7 AirEvac in collecting the charges for its services. I direct any insurers or health plans to acknowledge and act in accordance with this assignment. I hereby designate 24-7 AirEvac as my beneficiary related to all such rights and authorize 24-7 AirEvac to represent me and the Patient and to act on behalf with regard to any and all rights to which the Patient and/or I have, had, may have or will be entitled to, including all appeals and if necessary court action. I hereby authorize 24-7 AirEvac to release all medical information necessary to process any claim(s I hereby authorize any plan administrator fiduciary, insurer, attorney, and any other person in possession of information sought by MFS, to release to 24-7 AirEvac any and all plan documents, including, the Summary Plan Description, and all legally controlling documents.

related to such plan, insurance policy and /or settlement information upon request from 24-7 AirEvac in order to claim such benefits, reimbursement, or any applicable remedies. I authorize the use of my signature on all my insurance and/or employee health benefits claim submissions and any measures 24-7 AirEvac may require in order to obtain any plan documents, medical records, or any other information it deems necessary. I hereby convey to 24-7 AirEvac to the fullest extent permissible under the law and under any applicable insurance policies and/or employee health care plan any claim, chose in action, or other legal rights I may have to such insurance and/or employee health care benefits coverage under any applicable insurance policies and/or employee health care plan with respect to medical expenses incurred as a result of the medical services received from 24-7 AirEvac, its employees, contractors, and agents, and to the extent permissible under the law to claim such medical benefits, insurance reimbursement, and any applicable remedies. Further, in response to any reasonable request for cooperation, I agree to cooperate with 24-7 AirEvac in any attempts by 24-7 AirEvac to pursue such claim, chose in action or right against my insurers and/or employee health care plan, including, if necessary, to bring suit with 24-7 AirEvac against such insurers and/or other third-party payer in my name. Should this assignment be prohibited in part or in whole under any anti-assignment provision of my policy/plan, I request that such anti-assignment provision to be disclosed to 24-7 AirEvac within 30 days upon receipt of my assignment, otherwise this assignment should be reasonably expected to be effective and the anti-assignment provision shall be invalidated. I hereby grant any and all applicable and legal rights for 24-7 AirEvac to seek and obtain payment from any responsible third party. This assignment shall not be proscribed or limited in any manner. This assignment shall be irrevocable once 24-7 AirEvac has provided services. A photocopy of this assignment shall be as valid as the original. I have read and fully understand this assignment.
Today's Date: {todaysDate694}
Patient / Authorized Representative's Signature:*

Clear

Consent to Transport and Care
Patients's Name: {patientName}

Form Questions and Information (Optional)
Medical Diagnosis (Optional):
Doctor's Name (Optional):
Name of Medical Facility Patient is Being Transferred To (Optional):
1. Diagnosis and Need for Transport: The diagnosis of {patientName15} is {medicalDiagnosis}. I understand that Dr. {doctorsName} recommends transfer of this patient to {nameOf} for further diagnosis, treatment and care.

2. Authorization for Admission: Understanding the above patient’s condition, the undersigned executes this Consent to Transport andCare (the “Consent”) hereby consenting to the transfer of the patient by 24-7 AirEvac and to the admission of the patient to the abovenamed hospital. The undersigned further agrees to the performance of any emergency medical intervention by 24-7 Air Evac, which aredeemed necessary for the above patient.

3. Statement of Financial Responsibility: I understand that there is not commitment of financial assistance from any third party,including, but not limited to, insurance companies, Medicare, Medicaid, health care benefit plans employers, employee benefit plans,plan administrators or workers compensation carriers. I further understand and signify by my signature that I will be responsible forpayment of any provided services not covered by the applicable third party, including those charges deemed not medically reasonableand necessary by Medicare or any other insurance company. I promise to pay all fees, penalties, service charges and costs of collection,including, but not limited to, actual attorneys’ fees and all costs, including all taxable, nontaxable, collection, investigative garnishment,bank, expert, prejudgment and post judgment costs, incurred by 24-7 AirEvac in enforcing payment hereunder.

4. Authorization to Pay Insurance Benefits: I authorize payment directly to 24-7 AirEvac for fees which relate to, or arise out of, thisemergency air transportation and the provided care.

5. Procedure if Benefits Paid Directly to Me: In the event my plan, insurer or their authorized representative, submits any benefitpayment or reimbursement governed by paragraph 1 directly to me (or another individual or entity on my behalf) and not to 24-7AirEvac, I shall: (a) immediately contact 24-7 AirEvac by phone at 1-570-538-4488 and email at billing@billing911.com; (b) not deposit,cash, void, sign, destroy, damage, mutilate or alter the check in any way, unless otherwise instructed by 24-7 AirEvac; (c) not transfer,assign, send, mail, wire, convey, deliver or sign over the payment, or any portion thereof, to any individual or entity, unless otherwiseinstructed by 24-7 AirEvac; (d) immediately and continuously retain and safeguard the payment in my possession until otherwiseinstructed by 24-7 AirEvac; and (e) take all necessary measures and precautions to ensure that 24-7 AirEvac receives the entire paymentas expeditiously as possible, including, but not limited to, the following: (i) the execution of any documents or instruments required orrequested by 24-7 AirEvac, its’ billing administrator or any third parties involved in the coordination of payment to 24-7 AirEvac, includingbanks and other financial institutions, insurance companies, plan administrators, attorneys, accountants and government entities(collectively, the “payment Entities”); (ii) respond to every communication or correspondence from 24-7 AirEvac to me – whether byphone (including voicemails), email, text message, fax or mail – as quickly as possible but in no event later than twenty four (24) hoursafter such communication or correspondence was sent; (iii) immediately notify 24-7 Air Evac via email and phone should any of mycontact information change, including my home address, mailing address, work address, home phone number, cell phone number, faxnumber or email address; (iv) pay or agree to be fully responsible for all fees and costs associated with the transfer of payment to 24-7AirEvac, including any wire, transfer and bank fees or surcharges; (v) participate in any telephone or video conferences as required by the Payment Entities; and (vi) perform such other an further acts that may be necessary or convenient to ensure that 24-7 AirEvac receivesthe entire payment as expeditiously as possible.

6. No Liability for Tax Consequences: I acknowledge and agree that 24-7 AirEvac has not responsibility or liability for the taxconsequences or implications alleged to have been caused to me or my family based upon my receipt, deposit, assignment and/ortransfer of payments in accordance with paragraph 5 of this Consent, nor may I effectively rely on or use such tax consequences as adefense or justification to avoid, refuse, or delay, in any manner, my obligations created under paragraph 5. Accordingly, I hereby releaseand discharge 24-7 AirEvac and its officers, members, managers, attorneys, employees, representatives and affiliates harmless from anyand all liabilities, claims, demands, causes of action, obligations and responsibilities of whatever kind or nature, based upon or relating to my actions and those obligations as set forth in paragraph 5 above, including, but not limited to, any potential tax assignment and/ortransfer of payments in accordance with paragraph 5 of this Assignment.

7. I intend by this Assignment to convey to 24-7 AirEvac all of my rights to claim (or place a lien on) the medical benefits related to theservices, treatments, therapies and/or medications provided by 24-7 AirEvac, including rights to any settlement, insurance or applicablelegal or administrative remedies (including damages arising from ERISA breach of fiduciary duty claims). The Assignee and/or designatedrepresentative, 24-7 AirEvac, is hereby given the right by me to (a) obtain information regarding the claim to the same extent as me; (b)submit evidence; (c) make statements about facts or law; (d) make any request including providing or receiving notice of appealproceedings; and (e) participate in any legal or administrative claim or chose in action and pursue such claims or choses in action againstany liable party, insurance company, employee benefit plan, health care benefit plan or plan administrator. As my assignee anddesignated authorized representative, 24-7 AirEvac may bring suit against any such liable party, insurance company, employee benefitplan, health care benefit plan or plan administrator in my name with derivative standing at provider’s expense.

8. Unless revoked, this Assignment is valid for all administrative and judicial review under the patient Protection and Affordable Care Act(also commonly referred to as the Affordable Care Act), ERISA, Medicare and any applicable federal and state laws. A photocopy of thisAssignment is to be considered valid, the same as if it was the original.

9. The Construction and effect of this Assignment shall be governed by the laws of the State of California and any dispute arising under or inconnection with the Assignment or related to any matter which is the subject of this Assignment shall be subject to the exclusive venueand jurisdiction of the courts located in California. I hereby irrevocably consent to the personal jurisdiction of and venue in the state andfederal courts located in California with respect to any action, claim or proceeding arising out of or related to this Assignment and agreenot to commence or prosecute any such action, claim or proceeding other than in such courts. I HAVE READ AND FULLY UNDERSTANDTHIS ASSIGNMENT.

END
Patient / Authorized Representative Name: {nameperson}
Patient / Authorized Representative's Signature:*

Clear
Today's Date: {todaysDate694}

Designated of Authorized Representation Designee(s)
Patient Name: {patientName}
Patient's Date of Birth: {patientDate}
Name of Insured: {healthPlan546}
Insurance Provider: {insuranceProvider}
Insured ID Number: {insuredId}
Patient's Email: {patientEmail}
Patient's Telephone Number: {patientPhone}
I, {nameperson}, hereby designate and appoint 24-7 AirEvac and such other individuals as may be designated by 24-7 AirEvac in writing, as well as their respective employees, agents and contractors, to act as an authorized representative to pursue all claims and administrative appeals to recover payment for any and all benefits to which I and/or the above-named patient am/are or may be entitled under the terms of the plan/policy of the above-named insured as well as any other third party payor. I make this designation and authorization to the fullest extent permissible under applicable law and regulations so that the authorized representative(s) may pursue and prosecute any claims, appeals, and related rights, including with litigation, any appeal from and adverse benefit determination under the above- referenced plan, to act and to directly receive notifications, documents, benefit payments and any other right to which I am entitled.
Accordingly, any insurer and any other third party payer is hereby instructed to direct all information, notifications and other communications to which I am, or would be, entitled under the terms of the applicable plan, policy and applicable law, to my representative(s), including without limitations the initial determination and any supplemental/explanatory information, explanation of appeal rights and procedures, responses to request for documents, response to appeal, plan documents including applicable (SPDs) final administrative determination, benefit payments.
Federal law expressly prohibits interference with my right to make this designation. (29 CFR $2560.503(1)(b)(4)
A copy of this designation shall be considered as valid as the original.
Patient / Authorized Representative's Signature:*

Clear

HIPPA Compliant Authorization

To Disclose PHI Pursuant to 45 CFR Parts 160 & 164 (HIPPA)

A. Facility Questions (Optional)
Facility Released From:
Facility Name (Optional):
Facility Address (Optional):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Facility Phone (Optional):
Facility Released To:
Facility Name (Optional):
Facility Address (Optional):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Facility Phone Number (Optional):
Please enter a valid phone number.
Facility Email (Optional):
example@example.com

END
Patient Demographics
Patient Name: {patientName}
Insurance Provider: {insuranceProvider}
Patient's Date of Birth: {patientDate}
Insured ID Number: {insuredId}
Patient's Address: {patientHome}
Patient's Phone Number: {patientPhone}
Date of Service: {todaysDate694}

B. Facility Questions (Optional)
Pick-Up Facility (Optional):
Drop Off Facility (Optional):

END
Information Requested
I hereby authorize the above named provider or insurer to release the following confidential information to the person or entity name above:*

All RecordsHospitalizationDischarge SummaryH & PMental Health TreatmentSubstance Abuse TreatmentAIDS / STD ResultsOther
Consent for Release

Medical Information Release and Authorization (Optional)
I, or my authorize representative, request the disclosure of my protected health information as set forth on this form, in accordance with the HealthInsurance Portability and Accountability Act of 1996 (HIPPA). I understand that:

1) The Information to be released or disclosed may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome(AIDS), human immunodeficiency virus (HIV), alcohol and drug abuse, or mental health treatment, only if I have place my initials on the appropriateitems listed above.

2) I understand that signing this authorization is voluntary. My treatment or payment for my treatment is not conditioned on my authorization fordisclosure.

3) I have a right to revoke this authorization at any time by writing to the health care provider listed above, except to the extent information has beenreleased in reliance upon this authorization.

4) I understand that the information disclosed pursuant to the authorization may be re-disclosed by the recipient and no longer protected by the federall privacy regulations.

5) All items on this form have been completed by me and all of my questions have been answered.

This Authorization shall be in full force and effect until __________________; or until two (2) years from the date of execution, at which time this authorizationexpires

END
Patient's / Representative's Name: {nameperson}
Patient / Authorized Representative's Signature:*

Clear
Today's Date: {todaysDate694}
Relationship to Patient: {relationshipTo696}

Patient Consent & Assignment of Benefits
Patient's Name: {patientName}
Today's Date: {todaysDate694}

Transport Questions and Release Information (Optional)
Time of Service (Optional):

Hour Minutes

AM/PM Option
Transport # (Optional):
As a condition of receiving emergency transport and treatment by “24-7 AirEvac”, I hereby agree to the following:

Consent to Treatment: The undersigned consents to transport and treatment by 24-7 Air Evac deemed necessary in the judgement of the 24-7 Air Evac’s medical crew. I am aware that the practice of medicine is not an exact science. No representations or guarantees have been made regarding the result of the Services.

Insurance Certification & Authorization: I am patient responsibility for ensuring that all cortication or authorizations required by Medicare, Medicaid or any other private or public insurance carrier(s) or third party insurance carrier (collectively, “Insurance Carriers”) have been obtained. I recognize that my Insurance Carrier may reduce benefits if these are not obtained and that I am responsible for any balance not paid by it. I recognize that some or all of the Services may be deemed not medically necessary by my Insurance Carrier & that in such event I may be responsible for the entire unpaid balance of 24-7 Air Evac’s charges. I agree to sign any documents necessary to authorize 24-7 AirEvac to contest any insurance denial.

Guarantee of Payment & Assignment of Benefits: I agree to pay 24-7 Air Evac charges for the Services, including but not limited to any co-payment, deductibles or other expenses not covered by insurance. Unless otherwise specifically agreed or provided by law, all charges shall be due and payable on receipt of invoice. Unpaid accounts may bear interest 12% per annum not to exceed the maximum amount permitted by law. Without limiting the foregoing to the full extent necessary to pay 24-7 Air Evac’s charges in full & subject to any limitations imposed by applicable law assign & transfer to 24-7 Air Evac all my rights in & to:

(a) all insurance benefits whether such insurance is owned by me or not payable as a result of the injury or medical condition that necessitated the services:

(b) any & all proceeds paid or payable to me or on my behalf from any settlement, judgment or other award which is obtained as a result of the injury or medical condition necessitating the services.

(c) any causes or action that may be assigned according to applicable state law, which I now have or may have in the future against any person or entity arising directly or indirectly from the injury or medical condition which necessitated the services. To the full extent permitted by law, I specifically instruct any attorney, insurance agent, or other party who represents me to abide by this assignment & to disburse from the attorney’s trust account or other depository to 24-7 AirEvac any insurance proceeds necessary to pay 24-7 AirEvac’s chares in full. Acceptance of this assignment by 24-7 AirEvac shall not constitute an undertaking by 24-7 AirEvac or any duty to secure payment or any of the benefits hereby assigned. This assignment shall be deemed to be in substitution for right or remedy which 24-7 AirEvac may have to secure & obtain full payment of its charges directly from the undersigned. All rights & remedies 24-7 AirEvac pursuant to this agreement & by law are cumulative & the exercise or any right or remedy shall not be to the exclusion or the exercise or any other right or release.

Release of Liability for Personal Valuables: I understand & agree that 24-7 AirEvac is not responsible for personal valuables or belongings brought into the ambulance by me or any representative including but not limited to clothing, personal hygiene products, toiletries, dentures, glasses, prosthetic devices such as hearing aids, artificial limbs, medical assist devices, wallets, purses, credit cards, jewelry & money.

Consent for Release & Use or information: I authorize any holder of medical or other information about me to release Medicare, Medicaid, or any other insurance Carrier or their agents any information needed to determine benefits for this or a related claim, or for any other purpose permitted by law.

Acknowledgement of Receive or Notice of Privacy Practices: I acknowledge receipt of 24-7 Air Evac’s NOTICE OF PRIVACY PRACTICES. Release of Police Reports: I appoint 24-7 Air Evac as my representative under applicable state law for the purpose of obtaining police reports & other data related to the accident or incident for which services were provided.

Severability Entire Agreement Attorney’s Fees: In the event any provision of this Agreement is held to be invalid or unenforceable, it shall be deemed severed with the remaining portions continuing with full force and effect. This Agreement constitutes the entire Agreement between 24-7 Air Evac, the undersigned or any action or law or inequity is brought to enforce this Agreement 24-7 AirEvac shall be entitled to recover reasonable attorney’s fees and costs. The undersigned has read this agreement and has an opportunity to ask questions, has received satisfactory answers thereto and enters into this agreement voluntarily.

Arbitration: I agree to exclusively resolve any and all claims, disputes or controversies arising out of or relating to this contract for services (including its interpretation and application) by using a claim by an arbitrator before a neutral arbitrator pursuant to the rules of the American Arbitration Association (AAA) See, www.adr.org. AAA procedural rules and substantive law shall apply. This agreement extends to such disputes or claims against 27-7 AirEvac, other contractors and/or affiliated companies, entities, employees or individuals as intended third party beneficiaries to this agreement. I recognize that 24-7 AirEvac is a professional medical services provider which falls under the federal and state laws of California.

If the patient is unwilling to sign or physically or mentally incapable of signing, then an authorized representative must sign. PATIENT UNABLE TO SIGN (Must document physical, neurological, trauma limitation reasons:

END
Patient's Name: {patientName}
Today's Date: {todaysDate694}
Patient / Authorized Representative's Signature:*

Clear
Authorized Representative's Name: {nameperson}
Today's Date: {todaysDate694}
Patient / Authorized Representative's Signature:*

Clear

Ambulance Billing Authorization & Privacy Acknowledgement
Patient's Name: {patientName}

Transport Questions and Information (Optional)
Transport to (Optional):
I request that payment of authorized Medicare, Medicaid, or any other insurance benefits be made on my behalf to 24-7 Airevac for any services provided to me by 24-7 Airevac now or in the future. I understand that I am financially responsible for an amount in addition to that which was paid by my insurance. I agree to immediately remit to 24-7 Airevac any payments that I receive directly from insurance or any source whatsoever for the services provided to me and I assign all rights to such payments to 24-7 Airevac. I authorize 24-7 Airevac to appeal payment denials or other adverse decisions on my behalf without further authorization. I authorize and direct any holder of medical information or documentation about me to release such information to 24-7 Airevac and its billing agents, and/or Centers for Medicare and Medicaid Services and its carriers and agents, provided to me by 24-7 Airevac now or in the future. A copy of this form is as valid as an original.

END
ASSIGNMENT OF MEDICAL LIABILITY RELEASE FORM
Does Patient Choose to Refuse Ambulance Transportation Services?:*

YesNo
Medical Transport Company Name (Optional):
I herby release {medicalTransport}, its employees and administrative officers, from any liability or medical claim resulting from any refusal of Emergency Care and / or Transportation to the nearest recommended Medical Facility. I also acknowledge that AGAINST MEDICAL ADVICE and AGAINST COMPANY POLICY it is my unsolicited desire to:
Assignment of Medical Liability Release Form:

Refuse Ambulance TransportationRefuse the use of the Ambulance StretcherSeek other Medical Transportation or Medical Assistance
Patient / Authorized Representative's Signature:

Clear
Patient / Authorized Representative's Name: {nameperson}
Patient / Authorized Representative's Signature:*

Clear
Today's Date: {todaysDate694}

Client's Name:*

First NameLast Name
Patient's Name: {patientName}
Flight Number (Optional):
Today's Date: {todaysDate694}
This agreement is entered into on {date203} by the above-referenced client {clientName} for themselves and for the patient, {patientsName566}, and 24-7 AirEvac. Client and 24-7 AirEvac are referred to hereinafter individually as a “Party” or collectively as the “Parties”. WHEREAS 24-7 AirEvac is in the business of providing and arranging medical transportation and related services, and Client desires to receive such services for him/herself or for the Patient and Client agrees to be financially responsible for such services;

THEREFORE, THE PARTIES AGREE AS FOLLOWS:

1. 24-7 AirEvac shall utilize commercially reasonable efforts to arrange and/or provide services for patient. “Services” means the services arranged and/or provided by 24-7 AirEvac, its employees, agents and contractors, including without limitation, air transport, ground transport services and any related services, supplies and procedures, or any part thereof, and may also include commercial medical escorts, private charters, claims handling and such other services as 24-7 AirEvac may agree in writing to perform. Such services may include coordination of transport of the patient. 24-7 AirEvac may contract with air carriers licensed under Federal Aviation Regulations to conduct flight operations as necessary. Such carriers maintain full operational control of all aircraft performing flights for 24-7 AirEvac. Client understands that 24-7 AirEvac does not accept or handle Medicare claims, is not a Medicare provider, and use of 24-7 AirEvac’s services will not be paid by Medicare.

2. Term: This agreement commences as of the Effective date only after the Client has signed and returned it to 24-7 AirEvac and 24-7 AirEvac’s authorized representative has signed it, and shall continue until 24-7 AirEvac has received full payment for its services (the “Term”). Except for those provisions of this Agreement which are intended by their terms to survive the cancellation, termination or expiration hereof, 24-7 AirEvac will have no further obligations to Client or Patient.

3. 24-7 AirEvac’s Fees: Client agrees to be responsible for the charges and fees associated with the Services and will cooperate fully and diligently with 24-7 AirEvac in securing full payment from any third party who may be responsible for payment. All fees are due at the time Services are rendered. 24-7 AirEvac may require an advance payment of some or all of the total to be charged for the Services. The advance payment required for 24-7 AirEvac to perform Services for the Patient shall be $0.00 (plus a 5% administrative fee for any payment made by credit card) payable prior to the date of the transport. Unpaid amounts shall bear a late fee of 1.5% per month commencing thirty (30) days from the date of transport. Full costs of the Services may not be stated until the transport has been completed. However, the insurance company is charged our usual & customary rate. Client understands and agrees that 24-7 AirEvac’s position of an aircraft and/or the readying of a flight crew or medical team will cause 24-7 AirEvac to incur expenses that may require payment of up to the full amount of the charges set forth above even though the transport of Patient or other Services may be prevented or otherwise not provided in full, and Client shall make timely payment for such Services.

4. Cancellation: Circumstances may occur that result in the need for client to cancel a flight or ground transport. In such situations, Client shall provide a written, good-faith explanation of the basis for the cancellation and shall be responsible for any and all services provided, expenses incurred and resulting losses and/or damages.

5. Representations: Client and Patient have determined to accept Services from 24-7 AirEvac based on their own determination and/or the advice of their physician(s), and not based on any representation or advice of 24-7 AirEvac. 24-7 AirEvac makes no representations concerning the medical necessity or appropriateness of its Services in each instance.

6. Indemnification: Client, on behalf of itself and patient shall indemnify, defend and hold harmless 24-7 AirEvac, its affiliates, and their respective employees, officers, directors, managers, members, agents, representatives and vendors from any claims, damages losses and costs (including costs and reasonable attorneys’ fees and experts’ fees) arising out of any act or omission of Client, Patient, their family members, and/or any other persons associated with or under the control of client and/or Patient (“Associated Persons”). Notwithstanding any provision therein, this paragraph shall survive the termination, or expiration of this agreement.

7. Quality of Care/Materiality: 24-7 AirEvac goes to great effort to provide a quality service that meets or exceeds industry standards as it seeks to benefit its clients and patients. The parties agree that items such as the size, type, speed and color of aircraft utilized in air medical transport ar immaterial provided that such aircraft is capable of performing medical transport and may be utilized in the industry for air medical transport.

8. Independent Contractor Relationship: 24-7 AirEvac’s relationship with Client, Patient or any Associated Person, is and shall be only that of an independent contractor. The Parties do not intend any person other than the Client, Patient and 24-7 AirEvac to have any rights or remedies under this Agreement.

9. Choice of Law & Venue: This agreement shall be governed by the laws of the state of California without regard for its choice of law provisions. Subject to Section 13 herein, any dispute between the Parties arising out of or relating to this Agreement or the Services shall be filed in the state or federal courts of the he United States.

10. Construction: The Parties have had the right to negotiate the terms of this Agreement. Nothing herein may be construed against a party by reason of such Party having drafted a term or provision.

11. Force Majeure: 24-7 AirEvac, its affiliates, contractors, and their respective employees, agents, representatives, officers, directors, managers, and vendors shall not be liable for any delay in performance or non-performance under this Agreement caused directly or indirectly by any act of god or other cause beyond their control, including without limitation, fire, explosion, flood, war, government action, act of war, act of terrorism, inclement weather, strikes or labor disputes.

12. Limitation of Liability: IN NO EVENT SHALL 24-7 AIREVAC, ITS CONTRACTORS, OR THEIR RESPECTIVE AFFILIATES, EMPLOYEES, AGENTS OFFICERS, DIERECTORS, MANAGERS, OR MEMBERS: (1) BE LIABLE TO CLIENT, PATIENT OR ANY ASSOCIATED PERSONS FOR PUNITIVE, EXEMPLARY, INDIRECT OR CONSEQUENTIAL DAMAGES (INCLUDING WITHOUT LIMITATION, DAMAGES FOR LOST PROFITS) RELATED TO OR ARISING OUT OF THIS AGREEMENT OR THE SERVICES PERFORME, OR CONTEMPLATED HEREUNDER, WHETHER OR NOT CAUSE BY OR RESULTING FROM A BREACH OF CONTRACT, NEGLIGENCE, VIOLATION OF STATUTE, OR OTHER ACT OR OMISSION EVEN IF 24-7 AIREVAC HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES; OR (2) BE LIABLE FOR ANY AMOUNT GREATER THAN THE ACTUAL COSTS ASSOCIATED WITH THE SERVICES CONTEMPLATED OR PROVIDED UNDER THIS AGREEMENT.

13. Mediation and Arbitration: the Parties agree that all claims, demands, complaints, debts obligations, disputes and/or disagreements that arise out of/or relate in any way to this Agreement or the Services (“Claims”), except any claims by 24-7 AirEvac to recover charges for its Services, shall be submitted to mediation before litigation may be initiated. The mediation shall be held in California unless otherwise agreed by the Parties. The mediator’s fees shall be borne equally by the Parties. The parties shall participate in the mediation in good faith and must have an authorized representative with full settlement authority present. Upon the conclusion of the mediation, the mediator shall issue an opinion stating its findings and conclusions which shall be advisory only, confidential, and may not be used in arbitration, except 24-7 AirEvac’s Claims to recover charges for its Services. If arbitration is agreed upon by all parties, it shall be conducted by the American Arbitration Association in the State of California pursuant to its commercial rules unless provided otherwise herein. The Parties shall share equally in the costs of the arbitration without regard to which Party may prevail. The decision of the arbitrator shall be final, binding, and conclusive on the Parties and judgment may be entered on such decision in a court of competent jurisdiction.

14. Severability: If any term or provision of this Agreement is held to be invalid or unenforceable by a court of competent jurisdiction, the remaining provisions shall remain in full force and effect.

15. counterparts/Copies: This Agreement may be executed in any number of counterparts, each of which so executed shall be deemed to be an original and such counterparts together shall constitute one and the same agreement. A facsimile or other copy of this Agreement shall be as valid as the original.

16. Entire Agreement: Amendment; No third Parties: This Agreement, including any documents referenced in it and attachments hereto, contain the entire understanding of the Parties and supersedes all prior agreements between the parties with respect to the subject matter hereof. No modification, supplement or amendment of this Agreement shall be binding unless it is in writing and signed by duly authorized representatives of the Parties, and is not intended to confer upon any person other than the Parties (except as expressly provided herein for the benefit of the Patient) any rights or remedies hereunder.

WHEREFORE, THE PARTIES, THROUGH THEIR AUTHORIZED REPRESENTATIVES, ACCEPT AND ACREE TO ALL OF THE FOREGOING.
Client Signature:

Clear