ETMC EMS Membership

ETMC
PAID
Non-Profit Org
U.S. Postage
You are invited to enjoy greater peace of mind
ETMC EMS invites you to become a member in our ambulance service subscription program
that provides peace of mind by protecting you from unexpected ambulance costs. ETMC
EMS membership provides for the prepayment of copayments and deductibles for all
medically necessary ambulance services for which the patient has financial responsibility.
ETMC EMS membership also provides for a reduced fee for non-emergency transports that
are not covered by insurance. ETMC EMS membership is not an insurance policy or supplement.
Coverage includes your family
One ETMC EMS membership can include the applicant and immediate family members
living at the same address (coverage includes spouse and unmarried and financially
dependent children up to 21 years of age — 25 if a college student). A spouse who is
being cared for in a nursing home can be covered under the applicant’s membership.
ETMC EMS
Membership
Your rescue from unplanned
emergency expenses
Membership services — important features
ETMC EMS membership benefits are applied to emergency transports and nonemergency ground ambulance transports to hospitals in the ETMC EMS service area.
Patient preference usually determines the hospital to which the patient is transported.
However, in cases of life endangerment, the closest appropriate hospital will be used.
Emergency transports are fully covered for members with health insurance. If no
insurance or other third-party insurance is available, the ETMC EMS member is covered
for 50 percent of the ETMC EMS standard emergency fee and is therefore responsible
for payment of 50 percent of the total charges. An “emergency” is an unforeseen
medical condition which requires urgent and unscheduled medical attention.
Non-emergency transports are fully covered if insurance or other third-party coverage
provides benefits for the transport (even if subject to deductible, copay or coinsurance).
If no insurance or other third-party insurance is available, or insurance is denied by the
insurance company or other third-party payor, the ETMC EMS member is covered for
50 percent of the ETMC EMS standard emergency fee and is therefore responsible for
payment of 50 percent of the total charges. A “non-emergency” is a medical transfer in
which the patient is being transported for an ongoing medical problem for which he/
she has an appointment to be seen at the hospital or requires transport back to his/her
home or nursing residence following hospitalization for an acute medical problem.
Excluded Services: ETMC EMS membership provides no coverage for non-emergency
transports for which a certificate of medical necessity has not been completed by
the patient’s physician (forms available from ETMC EMS). The following destinations
are not included in coverage under the ETMC EMS membership program: doctors’
offices, dentists’ offices, physical therapy centers and pharmacies. Also not included are
transports to destinations which are not in the ETMC EMS service area. The patient
will receive a full bill for excluded services.
Agreement
In consideration and payment of the membership fee: I hereby assign to ETMC EMS all
ambulance benefits that I (or any covered family member) may otherwise be entitled to
receive from any insurance or other third-party payor for services provided under my
ETMC EMS membership, now or in the future. ETMC EMS will accept this assignment
as payment in full for emergency ground transports and for non-emergency ground
transports if insurance or other third-party payor coverage provides benefits for the
transport. I understand the ETMC EMS will file my ambulance insurance claims for each
covered person and is entitled to receive payment from all insurance or other third-party
payors up to the amount of the usual charges of ETMC EMS. If no insurance or other
third-party payor benefits are available or services are denied by the insurance company
or other third-party payor for the non-emergency services of ETMC EMS, I understand
that I will remain responsible for payment of the reduced fee of 50 percent of the
standard non-emergency fee of ETMC EMS. Any insurance or other third-party payment
that I receive related to ETMC EMS services provided under my ambulance membership
shall be delivered to ETMC EMS.
For information on ETMC EMS membership:
Call 1-800-642-JOIN (5646)
Special Offer
As little
as
P.O. Box 387
Tyler, Texas 75710
EAST TEXAS MEDICAL CENTER EMS
PO BOX 387
TYLER TX 75710-9905
TYLER TX
PERMIT NO. 22
FIRST-CLASS MAIL
POSTAGE WILL BE PAID BY ADDRESSEE
Low-cost membership fee structure
APPLICANTS WITH HEALTH INSURANCE:
New membership: $60
APPLICANTS WITHOUT HEALTH INSURANCE:
New membership: $68
BUSINESS REPLY MAIL
Please fold flap in on score, moisten gummed edges and seal.
NO POSTAGE
NECESSARY
IF MAILED
IN THE
UNITED STATES
Membership Description
and Agreement
60
$
*
could save you hundreds
in ambulance transports
DEADLINE SEPT. 30
Membership
Application
IMPORTANT NOTE: Medicaid recipients ARE
NOT ELIGIBLE.
I hereby apply for membership with my local
emergency medical service program. I understand
that the enclosed annual fee will cover me, my
spouse and my dependent children living in my
residence who are under age 21 or 25 if in college.
I understand that through this membership, East
Texas Medical Center EMS will provide emergency
ambulance service within the service area.
F n
emergency fees and I am therefore responsible for
payment of 50 percent of the total charges.
I understand that violations of the terms of this
agreement may result in immediate cancellation of my
membership or other penalty.
SOC. SEC. NO.
Amount
FIRST NAME & MIDDLE INITIAL
SOCIAL SECURITY NUMBER
SOCIAL SECURITY NUMBER
DATE OF BIRTH
DATE OF BIRTH
COUNTY
MEDICARE NO.
Fn
Check Number
FOR OFFICE USE ONLY
Date Received
SpouseM n
I understand that if I have no health insurance or thirdparty health insurance, my membership entitles me to
50 percent coverage of billed ETMC EMS standard
M n
FIRST NAMELAST NAME
Head of household
LAST NAME
PHONE NO.
FIRST NAME
DATE OF BIRTH
MEDICARE NO.
EMAIL ADDRESSDATE OF BIRTH
SOC. SEC. NO.
CITY, STATE, ZIP CODE FIRST NAME & MIDDLE INITIAL
(If additional space is needed, please use separate sheet.)
MAILING ADDRESS & APT. NO.
Household members’ information
M o LAST NAME
Fo
DATE OF BIRTH
YES
YES
o
o
NO
NO
GROUP NUMBER
SOCIAL SECURITY NUMBER
POLICY OR ID NUMBER
(If you don’t have health insurance,
skip to payment section.)
IS FAMILY COVERED? IS SPOUSE COVERED? o
o
FIRST NAME & MIDDLE INITIAL
(other than Medicare )
M o LAST NAME
Fo
M o LAST NAME
Fo
Health insurance information
CITY, STATE, ZIP CODE
INSURANCE COMPANY
INSURANCE COMPANY ADDRESS
(IMPORTANT: Must be signed to be valid.)
Payment information
Check the annual membership fee that applies to you:
o $60 (new membership with health insurance)
o $68 (new or renewed membership without health insurance)
o Personal Check or Money Order Please make check or money order payable to East Texas Medical Center EMS.
o VISA o MasterCard o American Express o Discover
Name on Credit Card________________________________________________ Card No.____________________________________ Exp. Date______________
I currently reside within the city of Mineola.
o I authorize a payment of $5 a month on the following water/billing system (available only to applicants with health insurance) :
Arp, Athens, Bullard, Craft Turney, Hideaway Lake, Mart, RPM Water Supply, Rusk, Rusk Rural Water, Troup and Tyler.
o NO PAYMENT ENCLOSED.
Membership in the East Texas Medical Center (ETMC) EMS program protects you from
these costly out-of-pocket expenses because it prepays any portion of the ambulance
charges not covered by insurance or Medicare.
Date
MUST LIVE IN THE ETMC EMS SERVICE AREA FOR MEMBERSHIP
For more information, visit our website at
etmc.org/emsmembership or call
1-800-642-JOIN (5646).
ETMC EMS covers all of Henderson County, most of Smith County and parts of
Cherokee, Collin, Harris, McLennan and Wood counties. Included is coverage
for medically necessary** transports to and from hospitals in Dallas/Fort Worth,
Houston and Lufkin.
You’re electronically enrolled in our system, so there’s no need to hunt for verification
when in need of our services.
ETMC EMS membership is card-free.
Not included is transportation to or from physicians’
offices, pharmacies, physical therapy centers, dentists’
offices or facilities outside the service area.
As a participant in the membership plan, you will pay a low annual fee, as little as $60
and no more than $68, payable by check, money order or credit card. In many cities, a
monthly installment plan is also available, to be paid through an assessment on each
month’s water bill. If you do elect to pay with your monthly water bill, please note that
you are making a one-year commitment and the fee must be paid each month for your
membership to be valid.
• Coverage for all qualified members of your
household (you, your spouse and your dependent
children living in your residence who are under age
21 or 25 if in college).
ETMC EMS thanks you for supporting your community’s
access to 24-hour ambulance care through your membership.
** “Medically necessary” is defined as specific need of ambulance transportation to or from a healthcare facility (hospital, nursing home)
within the ETMC EMS primary service area where use of alternative forms of transportation (wheelchair transports, private car, taxi) would be
medically inappropriate given the patient’s condition. ETMC EMS reserves the right to require physician certification of medical necessity for
all non-emergencies. If abuse is found to exist, ETMC EMS reserves the right to terminate membership.
I authorize any holder of medical information or documentation about me or any person covered under my East Texas Medical Center Emergency Medical Service (ETMC EMS)
membership to release to ETMC EMS and the Centers for Medicare and Medicaid Services and its agents and carriers any information or documentation needed to determine
benefits payable for services provided by any and all of my insurers and any third-party agencies. I further authorize my insurers and any third-party agencies to pay directly to
ETMC EMS whatever benefits or payments may be available for services rendered to me or my dependents by ETMC EMS, now or in the future.
I agree to provide ETMC EMS all information necessary to file a claim for payment under my insurance policy, plan or program or from any third-party payor.
Membership is nontransferable and nonrefundable and may be canceled upon member’s noncompliance herewith. Membership year October 1– September 30
• Full coverage of billed emergency transport charges for
members with health insurance.
As little as
*per year protects
you and your family
60
• Coverage of the portion of the bill not reimbursed by
insurance for medically necessary** non-emergency
transportation to or from a hospital or nursing home,
including any coinsurance and deductible.
To join the ETMC EMS Ambulance Membership program,
complete the attached membership application and mail
it in with your payment — no postage necessary.
Member’s Signature (Required for membership)
Low annual fee gives you peace of mind.
With ETMC EMS membership, you, your spouse and your dependent children living
in your residence (those under age 21 or 25 if in college) are covered for medically
necessary** transport by ETMC ambulances.
Your annual fee gives you the peace of mind that comes from knowing that in a time
of crisis, you won’t have the added worry of another big expense.
Complete membership application and mail it to address shown — no postage required!
Medical emergencies are stressful and involve unplanned expense. With an annual
ETMC EMS Ambulance Membership, you won’t have to worry about paying a costly bill
for emergency transport. That’s peace of mind you can’t put a price on.
Please remove application on perforated line.
ETMC EMS Ambulance Membership
benefits include:
$
• 50 percent coverage of billed emergency transport
charges for members without health insurance.
A costly bill you won’t have to worry about.
*$60 fee for a new membership with health insurance
$68 fee for new or renewed membership without health insurance
Don’t Delay! Membership deadline is Sept. 30.
Count on the one that covers East Texas.
I acknowledge that I am responsible for payment for the ambulance services provided for me.
Please sign after reading contract terms on reverse side.
And most insurance, including Medicare,
will not cover the full amount of an ambulance bill.
Enroll online at etmc.org/emsmembership
An average transport would cost $750.