Conditions of Membership Agreement
· Membership in the Bella Vista Ambulance
Services, Inc. entitles me (us)
to emergency transportation as many times per year as needed to a
hospital of our choice within the designated service area.
Final transport decisions, involving the destination hospital in
all emergencies, will be made by the Bella Vista EMS personnel and
Emergency Room Medical Control.
· I (we) agree that I (we) are legally
responsible for any and all services provided to me by the Bella Vista
Ambulance Services, Inc.
Should I have insurance or
medical benefits coverage, Bella Vista Ambulance Service, Inc. reserves
the right to bill directly
to all appropriate benefit providers for services rendered that are
medically necessary and covered by my insurance.
·
For members with insurance:
Medicare/insurance claims will be filed for members.
All insurance benefits must be paid to the Bella Vista Ambulance
Services, Inc., this will be considered as payment in full for ambulance
charges incurred with the Bella Vista Ambulance Service, Inc.
Mileage past the nearest appropriate facility and services not
covered/not medically necessary will be billed to the member.
· For members without insurance:
The member without insurance or whose insurance does not cover
your ambulance claim will pay 50% of the charges incurred with the Bella
Vista Ambulance Service, Inc.
The remaining 50% of the bill will be written off as the Member
Privilege.
· Bella Vista Ambulance Service, Inc.
considers an emergency to be a serious injury or illness or
deterioration in a condition, which, if not treated immediately, may
result in loss of life or limb, or may lead to permanent disability, as
determined by the emergency medical personnel.
· This is a membership and not an
insurance policy and is non-refundable.
· This agreement does not extend out of
the City to other cities. If
you have an ambulance call
in an area outside of the response area of the Bella Vista Ambulance
Service, Inc., you are not covered by this membership.
· This agreement does
not
cover non-emergency transports, mileage past the nearest appropriate
facility, services
not
covered by Insurances, and services
not
medically necessary. In the
event the patient requests the ambulance, then refuses transport; all
supplies/treatment provided will
not
be covered.
These expenses will be billed to
the
Member.
Revision Date:
08-09-07