Ground Membership Terms of Service

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This is not an application for an insurance policy.

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• I understand that the $100.00 membership fee ($75.00 for active members of The American Legion) for American Legion Ambulance Membership Program covers my portion of ground ambulance services that are medically necessary, and that are applied to co-insurance or deductibles by insurance or Medicare. "Medically necessary" is defined as a specific need for ambulance transportation to or from a health care facility (such as a 9-1-1 emergency call, non-emergency request, or an inter-facility transfer) within American Legion Ambulance's primary service area, where use of other forms of transportation, such as private car or taxi, would be medically inappropriate. I understand that American Legion Ambulance can require physician certification of medical necessity. I also understand that if abuse of the service is found to exist, my membership may be terminated.

• I understand that my membership covers those persons who permanently reside in my household and who are legal dependents. A "household" is defined as all persons who permanently reside at the "Head of Household's" physical address.

• I understand the membership is available only to residents of American Legion Ambulance's primary service area, which includes all of Amador and Calaveras Counties, excluding Ebbett’s Pass Fire Protection District area.

• I understand that this is not an insurance policy, nor is it meant to be a substitute for health insurance. I agree that if I have no insurance or other health coverage, or if my insurance company or other health benefits payer denies payment to American Legion Ambulance Service because it determines that my ambulance services were not payable, I will be responsible for the payment of the fees for those services. I agree to pay the fees for service less a 50 percent discount granted by American Legion Ambulance because I am a member.

• I understand that this membership plan does not cover the service given by other providers, including other 9-1-1 providers who provide back-up.

• Medi-Cal patients receive full coverage for services. Therefore, there is no reason for Medi-Ca patients to become members.

• I understand that ambulance transports are limited to 60 miles which covers Sacramento, Stockton and Modesto Areas. Transports over the 60 mile limit will be billed for mileage greater than 60 miles.

• I understand that my membership is non-transferable and non-refundable.

• I understand that the effective date for my membership is the date purchased and is effective for one (1) year from effective date.

• ASSIGNMENT OF BENEFITS: I understand that my membership is not an insurance plan and that American Legion Ambulance Service will bill and receive payments from my insurer or third party (such as Medicare, Blue Cross, etc.). I hereby authorize all benefits to be made directly payable to American Legion Ambulance. If I have Medicare, I request that payment or authorized Medicare benefits be made on my behalf to American Legion Ambulance for any ambulance service provided to me by American Legion Ambulance. If I receive payment from Medicare or my insurance company, I will immediately forward that payment to American Legion Ambulance. If I do not, I understand that my membership may be terminated and I will be billed full charges for services. I acknowledge that I am responsible for payment of ambulance services.

• LIFETIME SIGNATURE AUTHORIZATION: To facilitate processing, I authorize the release to American Legion Ambulance Service, the Centers for Medicare and Medicaid Services, or other insurer of any medical information or documentation held by anyone necessary to process a claim now or in the future, and further assign and authorize such payments to American Legion Ambulance. I permit a copy of this authorization to be used in place of the original.

• American Legion Ambulance Service is compliant with HIPAA regulations. Refer to our Notices of Privacy Practices.