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In consideration and payment of the $69 SEMS MEMBERSHIP fee, I hereby assign to SEMS all ambulance benefits that any covered household member or I may otherwise be entitled to receive from any insurance or other third-party payor for services provided by SEMS. I understand that SEMS will accept this assignment and file ambulance insurance claims for each covered person. SEMS is entitled to receive payment from all insurance or other third-party payors up to the amount of SEMS’s usual charges.

SEMS will accept the insurance or third-party payor's approved payment for emergency and non-emergency transport services. The SEMS MEMBERSHIP will cover the cost of deductibles and co-payments, and I will not be billed by SEMS for these expenses. If no insurance or other third-party payor benefits are available or if the insurance company or other third-party payor denies payment for services, I understand that I will be responsible for payment of said services at the reduced SEMS MEMBERSHIP rate, which is $100 for local emergency base rate; 50% reduction for non-emergency base rate; and 50% reduction for out-of-town mileage. I agree to provide SEMS with any valid insurance and/or third-party payor information, pertaining to me or any covered member of my household, within 60 days of receiving

ambulance service. In addition, I agree to furnish any information requested by my insurance company in order to facilitate payment of ambulance claims for me or any covered member of my household. Should I receive direct payment from insurance or a third-party payor for SEMS ambulance services, I agree to immediately forward the full amount received by me to SEMS. I understand that a violation of these terms voids the membership retroactively to the date of purchase. Non-transport services are not a covered benefit under this membership. SEMS MEMBERSHIP is non-refundable and non-transferable. I understand that this is a voluntary subscription, and if unable to purchase a membership it will not affect my ability to receive quality ambulance service. Patients are treated with equal care, regardless of membership status.

MEMBERSHIP becomes effective at time of purchase and expires June 30, 2023.

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