I understand that I am responsible for payment of ambulance services. The
annual $39 membership fee for Life Care Plus limits my out-of-pocket cost related
to ambulance transports covered by insurance ($59 membership fee for those
without insurance coverage) for medically necessary ground ambulance transportation
provided by Life EMS.
EFFECTIVE DATES:
I understand that my membership is effective upon receipt of full payment and
signed membership contract, and coverage is through April 30th of the year following
my sign-up.
IF I HAVE INSURANCE, WHO RECEIVES CLAIM PAYMENTS:
I understand that Life Care Plus is not insurance and that Life Care Plus will bill
for payments from my insurer or third party agency, (e.g. Medicare, BCBS, etc.)
including any supplemental or complementary insurance. If the insurance company
sends me a check for services rendered by LIFE EMS AMBULANCE, I
agree to promptly forward that check to LIFE EMS AMBULANCE. I hereby
authorize payment directly to LIFE EMS for ambulance services otherwise
payable to me. I authorize any holder of medical or other information about me,
to release to the Centers for Medicare and Medicaid Services (CMS), its agents,
other insurance carriers, or LIFE EMS, any information needed to determine
these benefits in the past, now or in the future.
WHAT IS MEDICALLY NECESSARY:
I understand that Life Care Plus Membership Services are restricted to “medically
necessary ambulance service”, defined as the specific need for ambulance
service transportation to and from a hospital within the LIFE EMS service area in
Kent, Ottawa, Kalamazoo, Newaygo, Lake, Ionia/Belding, Mason, Allegan counties,
Georgetown/Hudsonville/Jamestown areas and NE Van Buren County (specific
coverage area description available from the LIFE EMS business office), where
use of alternate forms of transportation (wheelchair van, private car, taxi) would
be medically inappropriate given the patient’s condition. LIFE EMS may require
physician certification of the medical necessity of ambulance transport. I understand
this membership can be terminated by LIFE EMS if it has evidence of abuse
of this program. Ambulance transport to such places as a physician’s office is not
covered.
IF SERVICES ARE NEEDED OUTSIDE THE LIFE EMS SERVICE AREA:
I understand that if long-distance, non-emergency ambulance services are
required outside the LIFE EMS service area, additional fees may be charged to
me by LIFE EMS.
ADDITIONAL SERVICES:
Wheelchair/Mobility Transportation and other services are available at special “member
only” discounted rates. Please contact the business office for details.
WHO IN MY HOME IS COVERED BY THIS PROGRAM:
The Life Care Plus program covers those residing in your household. A “household”
is defined as self and spouse, or single parent, their children under the age
of 21 years living at the same address, or a single individual household.
I UNDERSTAND THAT I MUST USE THE SERVICES OF LIFE EMS AMBULANCE IN
ORDER TO BE ELIGIBLE FOR MEMBERSHIP BENEFITS.
TERM OF THE MEMBERSHIP AGREEMENT:
I understand that my initial membership payment covers the time period from the
date on which Life EMS receives my signed contract and my full payment, and
continues until April 30 of the year following my sign-up.
Membership fees are not refundable, even if I attempt to terminate
during a term.
Serving you throughout the Greater Grand Rapids, Kalamazoo/Portage, Ionia/Belding,
Newaygo, Lake & Mason Co’s, Allegan, and now Georgetown/Hudsonville/Jamestown areas
and NE Van Buren County.
