Subscriber Form

Subscriptions

Online subscriber payment for residents of Bridgeville Borough, Cecil Township, and South Fayette Township
Please note that our memberships begin on April 1st of each year and expire March 31st of the following year.
Subscriber Head of Household*
Subscriber Address
Email
example@example.com
Phone Number*
Membership Code (if known)
i.e., 9912345
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
- Single - $50.00
  - Covers only one subscriber. Choose this if you live alone or want to cover only one family member.
- Seniors Couple - $60.00
  - Covers couples at the same household over the age of $65
- Household - $70.00
  - Covers all permanent residents at the subscribers residence. Choose this to protect your whole family.
- Household Plus - $80.00
  - Covers all permanent residents at the subscribers residence, plus any any guests who may need an ambulance while at that location.
- Additional donations are welcomed.

Subscription Plans

Single Covers only one subscriber. Choose this if you live alone or want to cover only one family member.

$50.00

Seniors Couple (Couples over 65) Covers couples at the same household over the age of 65

$60.00

Household Covers all permanent residents at the subscribers residence. Choose this to protect your whole family.

$70.00

Household PLUS Covers all permanent residents at the subscribers residence, plus any any guests who may need an ambulance while at that location.

$80.00

Additional Donations WelcomedAdditional donations are welcomed as they help support your area EMS operations.

$5.00 $5 Increment (see total donation below)
Item subtotal:$0.00

Total

$0.00

Credit Card

Additional Comments
I request that payment of authorized benefits be made on my behalf to SouthBridge Emergency Medical Service (EMS) for any ambulance services provided to me by SouthBridge EMS. I authorize any holder of medical information or documentation to release to SouthBridge EMS any information or documentation needed to determine these benefits or benefits payable for any services provided to me by SouthBridge EMS now or in the future. This is not a solicitation to medical assistance recipients. By clicking the "Submit Form" button below you are agreeing to the terms of this subscription.

Power of Attorney-click the arrow
Power of Attorney (P.O.A.)

First NameLast Name
Relationship to Member
P.O.A. Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
P.O.A. E-mail
example@example.com
P.O.A Phone Number

Click arrow to see the subscriber rules
THIRD PARTY BILLING

You are responsible for paying ambulance services provided to you by SouthBridge EMS, except as covered in this Membership Contract. SouthBridge EMS will file claims with all third party insurers, including Medicare. As a subscriber, you must agree to take all steps necessary to obtain maximum reimbursement from your insurance carrier. If you receive payments from your insurance carrier, you MUST FORWARD THE PAYMENTS TO SOUTHBRIDGE EMS at the address on the front of this form. If you do not forward payment to SouthBridge EMS, you will be billed for this amount.

WHY SHOULD I SUBSCRIBE TO SOUTHBRIDGE EMS IF I HAVE MEDICARE
OR OTHER INSURANCE?

Medicare and most insurance plans will not cover 100 of the bills incurred for ambulance service. An ambulance subscription can help reduce these out-of-pocket expenses. If 100% of your deductible has been met and your insurance company correctly processes and reimburses any portion of that bill, we accept it as payment in full provided the policyholder has complied with their insurance carrier's payment procedures. If 100% of your deductible HAS NOT been met, you will be charged 50% of your ambulance bill. No copayments under $200.00 will be billed to you. Non-subscribers will be billed the full balance and all copayments.

For more information regarding coverage please call 412-221-5115 ext.200

NON-COVERED SERVICES

Services not covered by the ambulance subscriptions are routine (non-emergency) transports, including but not limited to:
- Non-medically necessary hospital discharges
- Transports to and from physicians' offices
- Non-medically necessary ambulance transports
- Failure of a subscriber to take all necessary steps required by their insurance carrier to obtain maximum reimbursement
- Lift Assists
COVERAGE PROVIDED

Your subscription covers 50% of your unmet deductible and copays/coinsurances up to $200.00 for each medically necessary ambulance transport.

SouthBridge EMS bills all patients’ insurance for services rendered. Subscribers are not responsible for 50% of their unmet deductible amounts or copay/coinsurance amounts up to $200.00. Non-subscribers are responsible for all charges not covered by insurance. Uninsured Subscribers are billed 50% of their ambulance bill.

WHAT IS AN EMERGENCY?

The Health Care Financing Administration ties the definition of emergency ambulance service to the statutory definition of emergency services in a hospital room. The term "emergency" means services provided after the sudden onset of a medical condition manifesting itself by acute symptoms of such severity that the absence of immediate attention could reasonably be expected to result in the following:
- Placing the patient's health in serious jeopardy
- Serious impairment to bodily functions
- Serious dysfunction of any bodily organ or part
SUBSCRIPTION FEE

This subscription will terminate on the date indicated on the front of this form. YOUR SUBSCRIPTION WILL IMMEDIATELY TERMINATE WHEN YOU RELOCATE OUTSIDE OF OUR PRIMARY SERVICE AREA. SouthBridge EMS will not be responsible for the reimbursement of any other ambulance service.

PROOF OF MEMBERSHIP

Your check or credit card statement is your receipt. If you are transported, your membership will be verified by our staff.

REFUNDS

Subscription payments are nonrefundable.
Should be Empty:

Subscriptions

Please note that our memberships begin on April 1st of each year and expire March 31st of the following year.

Credit Card