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1-888-Life-EMS (543-3367)
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Membership Registration
  1. Membership Agreement & Application
    Complete form and pay on-line or mail check (note "on-line membership" on check) to:

    LIFE E.M.S.,Inc.
    1275 Cedar Streeet, NE
    Grand Rapids, MI 49503

    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 Medicad 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, lonia/Belding, Allegan and Mason counties (specific coverage area description available from the LIFE EMS business office), where use of alternate forms of transportation (wheelchair van, private care, 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 husband and wife, 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. This agreement automatically renews after the first term for successive twelve month terms when I make payment of the membership fee for that period, unless I provide written notice of termination to Life EMS at least thirty (30) days prior to the end of the first term or any renewal term. Membership fees are not refundable, even if I attempt to terminate during a term.

     


     

  2. Full Name(*)
    Please type your full name.
  3. Address(*)
    Please type your full name.
  4. City(*)
    Please type your full name.
  5. State(*)
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  6. Zip Code(*)
    Must be Numeric
  7. Phone (*)
    Must be Numeric
  8. E-mail(*)
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  9. Birthday
  10. Social Security Number
    Must be Numeric
  11. Do you have Medicare Coverage?
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  12. If yes: Medicare #
    Must be Numeric
  13. Do you have Blue Cross & Blue Shield insurance?
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  14. If yes: Contract #
    Must be Numeric
  15. Group #
    Must be Numeric
  16. Do you have other insurance?
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  17. If yes: Carrier Name
    Must be Numeric
  18. Contract #
    Must be Numeric
  19. Group #
    Must be Numeric
  20. Method of Payment(*)
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  21. Name on Card
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  22. Card Number
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  23. Card Expires
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  24. Card Security Pin
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  25. Do you have a spouse living at the same address that you wish to be included on this membership?
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  26. If yes: Spouse Name
    Must be Numeric
  27. Spouse Date of Birth
    Must be Numeric
  28. Social Security Number
    Must be Numeric
  29. Does your spouse have Medicare insurance?
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  30. If yes: Medicare Contract #
    Must be Numeric
  31. Medicare Group #
    Must be Numeric
  32. Does your spouse have other insurance coverage?
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  33. If yes: Carrier Name
    Must be Numeric
  34. Contract #
    Must be Numeric
  35. Group #
    Must be Numeric
  36. Do you have children under the age of 21 living at the same address that you wish to be included on this membership?
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  37. If yes:
  38. Child 1
  39. Name
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  40. Date of Birth
    Must be Numeric
  41. Social Security Number
    Must be Numeric
  42. Child 2
  43. Name
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  44. Date of Birth
    Must be Numeric
  45. Social Security Number
    Must be Numeric
  46. Child 3
  47. Name
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  48. Date of Birth
    Must be Numeric
  49. Social Security Number
    Must be Numeric
  50. Child 4
  51. Name
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  52. Date of Birth
    Must be Numeric
  53. Social Security Number
    Must be Numeric
  54. If you have additional children, please complete this form and then contact us to add to this list.
  55. If group policy is through work, who is the employer?
  56. Your Employer
    Must be Numeric
  57. Spouse's Employer
  58. Your Policy ID#
  59. Spouse's Policy ID#
  60. Do you have auto insurance?
  61. If yes:
  62. Auto Insurance Carrier
  63. Auto Insurance Policy #
  64. Subject *
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  65. By checking the signiture box, you are acknowledging your acceptance of the terms of the Membership Agreement above. Box MUST be checked for membership to be effective.(*)
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  66.    RefreshInvalid Input
  67.   

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