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Burns, OR
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PLEASE READ AND ACCEPT MEMBERSHIP AGREEMENT
I have read and agree to the benefits, terms and conditions of the Membership Plan as described below:
- The Membership benefits are for myself, my spouse and dependent children under age 23 (those claimed on my income tax return) and listed on this form.
- Harney District EMS and/or Air Life Membership is secondary to all other insurance carriers.
- Harney District EMS and/or Air Life will accept payment from insurance carriers as payment in full.
- I transfer directly to Harney District EMS and/or Air Life my rights to ground and/or air medical insurance payments due me. Such payments shall not exceed Harney District EMS and/or Air Life’s regular charges.
- Harney District EMS Memberships are honored by: Firemed Membership Programs of Oregon.
- Air Life Memberships are honored by: Life Flight of Boise, Idaho, and Portland, Oregon; Mercy Air Ambulance of Redding, California; Enloe Flight Care of Chico, California; Wyoming Life Flight of Casper, Wyoming; and Bannock Life Flight of Pocatello, Idaho, for medically urgent air transport to the closest medically appropriate facility.
- New member benefits take effect seven days after receipt of completed enrollment with payment.
- Air Life's elective medical flight benefits take effect 30 days after enrollment. Participation in the Air Life Membership Plan entitles me, or any of my listed family members, to a discount on air medical expenses incurred for an elective medical flight provided only by Air Life of Oregon. Elective medical transports are by airplane only and require scheduling and payment arrangements 24 hours in advance.
- Both ground and air emergent medical transports are based on medical need, not Membership status, and transport patients to the closest, medically appropriate facility as requested by physician.
- Availability of service cannot always be guaranteed due to weather conditions or commitment to another transport.
- Harney District EMS Membership covers ground ambulance charges only.
- Air Life Membership covers air ambulance charges only.
- Harney District EMS/Air Life package Membership covers ground and air ambulance charges.
- No refunds will be issued on Membership purchases.
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