FireMed Ambulance Membership Program Terms of Agreement

By Joining FireMed, Members Agree to Abide by the Terms of Agreement below.

Definition: FireMed is a voluntary ambulance membership program operated by the City of Ashland.  FireMed is not insurance.  All coverage for services is in addition to any medical benefits members may have.  FireMed will bill insurance or other coverage that members may have for ambulance services costs that members may have incurred and FireMed is entitled to all benefits paid by insurance for ambulance services rendered, up to the total dollar amount of services incurred.

Membership Benefits: Membership covers applicable patient out-of-pocket expenses for medically necessary ground ambulance transportation to any local area hospital.  "Medically necessary ground ambulance transportation" means that the patient must be transported to a hospital for medically necessary services, and transportation in any other vehicle could endanger their health.

Membership Benefits Outside of Local Service Area: Other participating reciprocal agencies may extend member benefits to areas outside our ambulance service area.  These benefits are limited to the terms of agreement in effect by the participating agency providing services at the time benefits are used.  Members who receive ambulance service from any other participating agency are eligible for benefits offered by that agency.  The member agrees to abide by the participating agency's terms of agreement.  A current list of participating agencies is on file in the FireMed business office and on our website (www.firemed.org).  FireMed is not responsible for the type, level, or quality of services provided by a participating agency nor is FireMed financially responsible for any costs or charges incurred by a member from any other ambulance provider.  FireMed is not responsible for the withdrawal of participating reciprocal agencies.  Participating agencies are subject to change without notice.

Member Responsibilities: Members pay an annual membership fee and will assign and transfer to FireMed all rights and reimbursements for ambulance services from all insurance policies, plans, or other benefit programs members may have, including all rights in any claim or third party recovery, up to the total dollar amount of services incurred, where ambulance services were provided by FireMed.  Should any person covered under this membership receive any payment for ambulance services rendered by FireMed, they will immediately forward such payment to FireMed.  Members authorize the release of medical and other information by or to FireMed as necessary for ambulance billing.  Members agree to provide, when requested, any or all information concerning insurance policies, plans, third party recovery, or other benefit programs they may have, and will cooperate and assist as necessary in any efforts to bill and collect such ambulance reimbursements, including the completion and submission of documents or claim forms.

Membership Eligibility: Residents of the FireMed ambulance service area are eligible to join by properly completing an enrollment application available from FireMed and by paying the appropriate annual membership fee.  FireMed household membership includes all persons who are permanent residents of the same single-family occupancy, non-commercial residence, within the FireMed ambulance service area, living together as a family unit, including domestic partners, but not to include roomers or boarders.  Membership benefits include dependent household members living in substitute care (e.g.  nursing homes) in the FireMed ambulance service areas.  Others not included in this definition are required to obtain their own separate membership.  The first person listed on the application form is called the "Primary Member." Anyone who joins a household after the membership goes into effect can be included under the membership from the date the "Primary Member" notifies FireMed of the addition.  Only those persons who meet the membership eligibility requirements AND are listed in the membership record at the time services are rendered are eligible for benefits.

Duration: Membership coverage begins upon acceptance of a properly completed application form with payment and extends to October 31, 2017.

To the Member's Insurance Carrier (for members with insurance): As a FIREMED member, I authorize use of a copy of this agreement in place of the original on file at the FIREMED office. I assign and authorize payment of benefits for ambulance services directly to FIREMED, according to the FIREMED terms of agreement and as itemized on claim forms. My membership fee covers any applicable deductible, coinsurance, or co-payment amounts and I expect the usual and customary ambulance reimbursement on my behalf be sent directly to FIREMED.

Disclaimer: FIREMED reserves the right to add, modify, or delete any of the program terms and conditions completely or in part. All interpretations of the membership terms and conditions shall be at the sole discretion of FIREMED. Membership is non-transferable and non-refundable. Persons who receive welfare, Medicaid, Department of Medical Assistance Programs, or Oregon Health Plan medical benefits need not be members in order to have full coverage for services covered under these programs. Any such membership constitutes a voluntary contribution only. Violations of the terms of agreement may result in membership revocation, forfeiture of benefits associated with membership and an obligation to pay all balances in full.

FireMed Plus Benefits in Addition to Basic, Mercy Flights Inc.  Air Ambulance Option: Mercy Flights services include ground ambulance within the Mercy Flights Jackson County assigned service area, Fixed Wing Air Ambulance within 1000 air miles and Helicopter Ambulance within 150 air miles of Medford, OR, in the continental United States.  I understand that Mercy Flights is not an insurance plan, and will bill whatever insurance or medical benefits I may have and/or be entitled to for services rendered by Mercy Flights.  I also understand that Mercy Flights membership fees are non-refundable and there is a 30-day waiting period for member benefits to take effect.  I understand that I will be responsible for any denied, disallowed, or non-medically necessary transports, as determined by my insurance company or other third party payer.  If I do not have any insurance, I will be responsible for a portion of the bill.  Should I or a covered family member receive payment from insurance or other medical benefits for ambulance services rendered by Mercy Flights, I will immediately forward such payment to Mercy Flights.  The Mercy Flights membership is not solicited from persons who receive Medicaid medical benefits and such membership constitutes a voluntary contribution only.  I understand that violation of such terms of this agreement or substantiated abuse of ambulance services may result in cancellation.

Mercy Flights Eligibility: Eligible household members consist of the head of household, spouse, and immediate family members who live at the same physical location, are legal dependents (as determined by Internal Revenue Service guidelines) and are under 19 years of age.  These legal dependents can include unmarried dependent full-time students, under the age of 22, who reside at a different physical location or a spouse who resides in a care facility.  Qualifying household members also include: disabled children, minor children of non-custodial parents, domestic partners, and dependent parents residing at the same physical location.  Disabled children and dependent parents will continue their membership, if they move from the household into a care facility.

Notice: This Mercy Flights, Inc.  Ambulance Plan is not an insurance program.  Membership benefits are for services provided by Mercy Flights, Inc.  only.  It will not compensate or reimburse another ambulance company that provides emergency transportation to you or your family.  Other ambulance company transports may occur if Mercy Flights is unable to perform within a medically appropriate time frame.  This may occur, but is not limited to, a mechanical or maintenance problem or being on another call.  This may also occur if the emergency location is outside of Mercy Flights' assigned service area.  If the other transporting ambulance company has a signed reciprocity agreement with Mercy Flights, that agency's membership benefits will be applicable to the transport.

For further information on FireMed Basic and FireMed Plus, please call any of our staff at 541-488-6009.

Revised 02/15

By sending your check, you authorize FireMed to use the information on your check to make a one-time electronic debit from your account.  Your original check will be destroyed once processed, and you will not receive your cancelled check back.  If you do not wish to participate in this check conversion program or have further questions regarding this process please call FireMed Membership Services: 541-488-6009, Monday-Friday, 8-5 pm.  Thank You.