Samaritan EMS Ambulance Service Membership Agreement and Consent Form
I hereby apply for a Samaritan EMS Ambulance Service Membership for myself and my household which includes spouse/domestic partner, parents, children, grandchildren, or siblings of mine or my spouse/domestic partner living in my residence and have listed each household member's name on the form where appropriate.
Membership covers MEDICALLY NECESSARY emergency ambulance trips to or from hospitals originating in the Samaritan EMS Yukon, Oklahoma response area. This membership covers 5 residents of the household. If more than 5 residents are needed a 2nd subscription must be purchased. Samaritan EMS Ambulance Service Membership is not an insurance policy. Membership does not cover: (1) trips for patients who can safely walk, (2) safely sit in a wheelchair, or (3) be transported safely by private car or taxi. Membership only covers MEDICALLY NECESSARY TRANSPORTS. [Medicare guidelines and/or you private insurance carrier determine medical necessity.] Other restrictions may apply.
A Physician Certification Statement (PCS), or Certificate of Medical Necessity (CMN) documentaing the MEDICAL CONDITION that makes ambulance transportation a MEDICAL NECESSITY is required for all non-emergency trips and may be required on emergency trips that are denied by Medicare or other third party agencies. Pre-Authorization must be secured prior to non-emergency transports for those patients whose insurance requires such authorization.
The membership fee is non-refundable, and membership is non-transferable!
Membership permits Samaritan EMS to collect directly from any third party agency (private insurance, Medicare, VA, etc.) benefits that may be available. Members and their household members are legally responsible to pay for Samaritan EMS services. Samaritan EMS will accept any available third-party benefits as payment in full for qualified transports.
Emergency transports are fully covered when medically necessary. An "emergency" is an unforeseen medical condition which requires urgent and unscheduled medical attention. Transports are fully covered if insurance or other thard party coverage provides payment toward benefits for the transport. If no insurance or other third party coverage is avaialble or benefits are denied by the insurnace company or third party payer, Samaritan EMS members are charged a reduced fee (60% of billable charges).
PLEASE SIGN AND RETURN COMPLETED FORM TO SAMARITAN EMS
Please note: All adult household members must sign.
I hereby assign Samaritan EMS all rights and benefits of mine and of my dependants for ambulance services provided by all third-party agencies. I further authorize all third-party agencies to pay directly to Samaritan EMS benefits that may be available for services rendered to me or my dependents by Samairtan EMS, and I agree to help Samaritan EMS collect these benefits. If I receive a payment directly from any third-party agency, I will immediately forward the payment to Samaritan EMS. If I fail to comply, I understand my membership can be terminated and regular charges for all services will be immediately due.
I hereby authorize any holder of medical, hospital or other records and information about me or my dependents to release to Samaritan EMS, third party agencies, the Center for Medicare and Medicaid Services (CMS) and its intermediaries any information needed to determine third party benefits payable for any services provided to me or my dependents by Samaritan EMS now or in the future.