Primary Membership Care Application

I acknowledge that my insurance provider or I am responsible for payment of ambulance service provided to me by Bartlesville Ambulance. In consideration and payment of the membership fee, I hereby assign to Bartlesville Ambulance all 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 Primary Care membership. Bartlesville Ambulance will accept this assignment as payment in full for emergency ground transport if insurance or other third-party payor coverage provides benefits for the transport. I understand Bartlesville Ambulance will file my ambulance insurance claims for each covered person and is entitled to receive payment for all insurance, Medicare or other third-party payor up to the amount of Bartlesville Ambulance’s usual charges. For non-emergency services, a Physician’s Certification Statement must be signed by the patient’s physician. If the physician states the ambulance was not medically necessary and the patient or family wants ambulance transport, Primary Care Members will be billed 60% of the standard non-emergency charge. For Primary Care Members not qualifying for non-emergency ambulance transport, a Wheel Chair Service is available with a $5.00 reduction from the standard Wheel Chair Transport charge. Any Medicare, Insurance or other third-party payment I receive related to Bartlesville Ambulance’s services will be immediately delivered to Bartlesville Ambulance. I also understand that Bartlesville Ambulance’s services area is 20 miles radius, that the Primary Care membership is only good in the service area.