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North Fork Ambulance Association Program Agreement - As of September 2017

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North Fork Ambulance Association Membership Program:

By signing the North Fork Ambulance Membership Application (”Application”), the members listed on the Application shall abide by the terms of the North Fork Ambulance Membership Program as set forth in this Agreement.

North Fork Ambulance Association Membership Program: The North Fork Ambulance Association Membership Program (the “Program”) is a voluntary ambulance membership program operated by the North Fork Ambulance Association (North Fork Ambulance). The Program is not insurance, rather, it is in addition to any medical benefits that a member may have. North Fork Ambulance will bill member’s insurance or other coverage for ambulance services that a member may receive.

The North Fork Ambulance is entitled to all amounts paid by member’s insurance or other coverage for North Fork Ambulance services, up to the total dollar amount charged by North Fork Ambulance for the services provided. In the event a member’s insurance or other coverage for ambulance transport services as provided by North Fork Ambulance is remitted directly to a member, the member shall remit such funds directly to the North Fork Ambulance.

Membership Benefits: Membership covers or waives applicable patient out-of-pocket expenses for co-pays on medically necessary ground ambulance transportation provided by North Fork Ambulance.

Additional Benefit: In the event ambulance service rendered by North Fork Ambulance to the Member is not covered by the member’s insurance due to lack of medical necessity as determined by the Center for Medicare/Medicaid Services or the Member’s private insurance company, unmet deductible, failure to comply with applicable coverage requirements, or for any other reason, or if the member has no applicable insurance; the North Fork Ambulance shall provide the member with a sixty percent (60%) discount off its usual and customary charge for such transport.

Persons Covered: This agreement covers those members listed on the North Fork Ambulance Membership Application, be they part of the household, business employees or patrons; so long as they remain full-time members of the specified household or so long as the business remains a member.

New household members may be added, members may be deleted or the household or business location may be changed by written notice to the North Fork Ambulance, effective the day following receipt by North Fork Ambulance of such notice.

Cost of Membership: To become a North Fork Ambulance member, the member hereby pays North Fork Ambulance a non-refundable and non-transferable fee in the amount specified in the Application. The member warrants all the information in the Application is true and correct. The North Fork Ambulance reserves the right to request documentation demonstrating the accuracy of such information.

Duration of Membership: Membership coverage begins five (5) business days after acceptance of a properly completed application form with payment and extends for one (1) year from the date coverage begins.

Responsibility for Payment and Consent to Release of Medical Information for Billing and Payment: Except as otherwise expressly provided in this Agreement, the Program member acknowledges that he or she is financially responsible for the emergency medical services provided regardless of insurance coverage. The Program member authorizes and directs any holder of medical information or documentation about him/her to release to the centers for Medicare and Medicaid Services and its carriers and agents, North Fork Ambulance and its billing agents and any other payers or insurers, any information and/or documentation needed to determine these benefits or benefits payable for the emergency medical services provided pursuant to this agreement.

By signing the Application, the Program member authorizes use of a copy of this Agreement in place of the original on file with North Fork Ambulance and further directs Medicare/Medicaid, its carriers and agents and any other payers or insurers to remit payment on member’s behalf directly to the North Fork Ambulance Association.

Disclaimer:
North Fork Ambulance has the right to add, modify or delete any of the Program terms and conditions completely or in part. All interpretations of this Agreement and conditions shall be at the sole discretion of the North Fork Ambulance Association. Membership is non-transferable and non-refundable. Violations of this Agreement may result in membership revocation, forfeiture of benefits associated with membership and an obligation to pay all balances in full.

The North Fork Ambulance in its sole and absolute discretion, reserves the right to terminate any membership based on abuse of the Program by a member.


North Fork Ambulance
PO Box 127
Hotchkiss, CO 81419
(970) 872-4303
office@northforkambulance.com

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