Enrollment & Assignment
I understand that I am legally responsible to pay for services provided by Pope County EMS. Membership fees are non-refundable and non-transferable. I assign to Pope County EMS on behalf of myself and those family members covered by this membership, all rights and benefits under any and all medical or health insurance policies (or plans) and all other medical benefit programs or plans which provide coverage for emergency ambulance services. Family memberships include head of household, spouse/life partner, and unmarried children under age 22.
Membership Services
Emergency services are provided to and from HOSPITALS within Pope County EMS’s service area. I understand that if my condition so indicates, Pope County EMS or the medical control physician may select the hospital to which I will be taken. Pope County EMS agrees to provide medically necessary non-emergency services according to the terms of the contract. In addition to local non-emergency service, Pope County EMS has established a one hundred (100) mile extended coverage radius around Pope County for medically necessary transports from our service area to hospitals outside of Pope County. Services to and from hospitals within the extended coverage radius are provided subject to the terms of this agreement. I understand that emergencies and service area coverage have first priority and that all dispatching/staffing decisions are the sole right of Pope County EMS.
Medical Necessity
Services covered under this agreement must be MEDICALLY NECESSARY. I understand that membership services with respect to emergency transports are restricted to situations where I and/or my family members have sustained injury, sudden illness or trauma and the need for the immediate medical attention of a doctor at a hospital emergency room exists. I understand that in the event non-emergency transport is requested (i.e., no sudden injury, illness or trauma requiring the immediate medical attention of a doctor at the hospital emergency room) physician authorization and/or a Physician Certification Statement (PSC) form may be required as a condition of transport. In most cases, medical necessity is determined by the patient’s physician, however, Pope County EMS reserves the right to determine medical necessity for non-emergency service or to request a signed physician certification statement prior to transport.
Third Party Reimbursement
As a member, I agree and consent to Pope County EMS filing for and collecting payment for services provided under any and all medical or health insurance policies, plans, or benefit programs, up to the amount of the provider’s charges for ambulance services provided to me and/or my family members covered herein. Pope County EMS agrees to accept the amount paid by the plan as payment in full. Any payments made directly to a member must be turned over in full immediately. I authorize any holder of any information about me to release it to Medicare (CMS), its carriers or agents, as well as to Pope County EMS, and to pay all benefits for ambulance service directly to Pope County EMS now or any future qualifying transports by Pope County EMS. Failure to provide necessary information concerning available insurance or medical benefits, or failure to forward any amount paid to the member for services shall result in revocation of membership. This agreement is exclusively executed between the members listed on the application and Pope County EMS. Membership does not exclude facilities and providers subject to Medicare’s Consolidated Billing and Prospective Payment System (CB/PPS) for skilled nursing facilities from paying for ambulance services. Membership is non-transferable to contracts with facilities subject to CB/PPS guidelines without prior authorization by Pope County EMS.
Member Payments / Member Discount
Membership DOES NOT guarantee any out-of-pocket expense for ambulance service. Pope County EMS agrees to reasonably pursue all payer sources prior to billing the member the discounted rate. Such services may be billable even if the transport was physician authorized.
Members who have Medicaid only (no other coverage), should not purchase a membership as you already have benefits for covered services.
I have read and understand the terms of membership. Upon Pope County EMS acceptance of my application, I agree to abide by the terms and conditions of the ambulance membership program.
