MEMBERSHIP ENROLLMENT AGREEMENT
ANDERSON VALLEY AMBULANCE SERVICE and REACH 2017 – 2018
To obtain membership program coverage through June 30, 2018, please complete the form below. The online payment must be made by PayPal or by credit card through PayPal guest checkout.
A completed Agreement is required for any option.
Please take time to read and fill out completely; an incomplete application may delay your coverage.
Prices shown below are for annual membership for you and your Other Family Members listed below. Please check one or more boxes.
Once your application has been submitted, please click here to make a PayPal payment: PayPal. Your application cannot be validated without a payment.
NOTICES REQUIRED BY THE DEPARTMENT OF MANAGED HEALTH CARE:
BEFORE YOU PURCHASE:. If you are currently enrolled in a health maintenance organization (HMO) or other health insurance, the benefits provided by an Ambulance Plan may duplicate the benefits provided by your HMO or other health insurance. If you have a question regarding whether your HMO or other health insurance offers benefits for ambulance services, you should contact that other company directly.
WARNING: This Ambulance Plan(s) is not an insurance program. It will not compensate or reimburse another ambulance company that provides emergency transportation to the person(s) listed on this form. This may occur when the
911 Emergency System has independently determined that another company could provide more expeditious service or is next in the rotation to receive a call. This might also occur when this Ambulance Plan is unable to perform within a medically appropriate timeframe due to a mechanical or maintenance problem or being on another call.
COMPLAINTS: For complaints regarding this Ambulance Plan, or if you have questions regarding the Plan, first attempt to call the carrier providing services: Anderson Valley Ambulance Service : 1-(707) 895-3123 ; REACH: 1-(800) 793- 0010 . If the organization fails to resolve the complaint to your satisfaction, contact the Department of Managed Health Care (DMHC) at 1 -(888) 466-2219 . The Department’s webs ite is http://www.healthhelp.ca.qov. You may obtain complaint forms and instructions online.
OPERATING UNDER CONDITIONAL EXEMPTION: This Ambulance Plan is operating pursuant to an exemption from the Knox-Keene Health Care Service Plan Act of 1975 (Health and Safety Code section 1340 et seq.).
Please make a copy of this Agreement for your records, if you think you will want to refer to it later.
OTHER IMPORTANT DETAILS: AVAS and REACH are emergency services, activated under County protocols by an emergency 911 response service or physician’s prescription only. Membership benefits apply to qualifying transports only. AVAS and REACH membership is secondary to all other insurance carriers. AVAS and REACH will accept payment from insurance carriers as payment in full. Members transfer directly to AVAS and REACH their rights to medical insurance payments due them. Members also agree to complete any forms or take other reasonable actions needed to collect such payments, which shall not exceed regular charges for AVAS or REACH. New member benefits take effect 15 days after receipt of completed enrollment with payment. To qualify as renewal this agreement and payment must be received within 30 days of expiration of prior membership. Coverage is only valid for services provided directly by AVAS, REACH or a Reciprocal Partner Program. AVAS and REACH transport patients based on medical need, not membership status, and transport patients to the closest, medically appropriate facility as requested by a physician or under County protocols by activation under the emergency 911 system. There may be times when AVAS and REACH are not available.
REACH membership does not cover any ground ambulance charges, including transportation to and from aircraft.
AVAS membership does not cover any air ambulance charges. No refunds will be issued on Membership purchases. The AVAS and REACH Membership Plan benefits are for you and your family as defined on this form. Memberships are not transferable. If you, as a member, receive a bill from AVAS or REACH please contact us and provide us with your Membership number. AVAS and REACH will not pay for transportation performed by another company.
REACH Air Medical Services/AMCN
AirMedCare Network is an alliance of affiliated air ambulance providers* (each a “Company”). An AirMedCare Network membership automatically enrolls you as a member in each Company’s membership program. Membership ensures the patient will have no out-of-pocket flight expenses if flown by a Company by providing prepaid protection against a Company’s air ambulance costs that are not covered by a member’s insurance or other benefits or third party responsibility, subject to the following terms and conditions:
1. Patient transport will be to the closest appropriate medical facility for medical conditions that are deemed by AMCN Provider attending medical professionals to be life- or limb-threatening, or that could lead to permanent disability, and which require emergency air ambulance transport.A patient’s medical condition , not membership status, will dictate whether or not air transportation is appropriate and required. Under all circumstances, an AMCN Provider retains the sole right and responsibility to determine whether or not a patient is flown.
2. AMCN Provider air ambulance services may not be available when requested due to factors beyond its control, such as use of the appropriate aircraft by another patient or other circumstances governed by operational requirements or restrictions including, but not limited to, equipment manufacturer limitations, governmental regulations, maintenance requirements, patient condition, age or size, or weather conditions. FAA restrictions prohibit most AMCN Provider aircraft from flying in inclement weather conditions. The primary determinant of whether to accept a flight is always the safety of the patient and medical flight crews. Emergent ground ambulance transport of a member by an AMCN Provider will be covered under the same terms and conditions.
3. Members who have insurance or other benefits, or third party responsibility claims, that cover the cost of ambulance services are financially liable for the cost of AMCN Provider services up to the limit of any such available coverage. In return for payment of the membership fee, the AMCN Provider will consider its air ambulance costs that are not covered by any insurance, benefits or third party responsibility available to the member to have been fully prepaid. The AMCN Provider reserves the right to bill directly any appropriate insurance, benefits provider or third party for services rendered, and members authorize their insurers, benefits providers and responsible third parties to pay any covered amounts directly to the AMCN Provider. Members agree to remit to the AMCN Provider any payment received from insurance or benefit providers or any third party for air medical services provided by the AMCN Provider, not to exceed regular charges. Neither the Company nor AirMedCare Network is an insurance company. Membership is not an insurance policy and cannot be considered as a secondary insurance coverage or a supplement to any insurance
coverage. Neither the Company nor AirMedCare Network will be responsible for payment for services provided by another ambulance service.
4. Membership starts 15 days after the Company receives a complete application with full payment; however, the waiting period will be waived for unforeseen events occurring during such time. Members must be natural persons. Memberships are non-refundable and non-transferable.
5. Some state laws prohibit Medicaid beneficiaries from being offered membership or being accepted into membership programs. By applying, members certify to the Company that they are not Medicaid beneficiaries.
6. These terms and conditions supersede all previous terms and conditions between a member and the Company or AirMedCare Network, including any other writings, or verbal representations, relating to the terms and conditions of membership .
*Air Evac EMS, Inc. I EagleMed LLC I Med-Trans Corporation I REACH Air Medical Services, LLC -These terms and conditions apply to all AirMedCare Network participating provider membership programs, regardless of which participating provider transports you.