TERMS OF AGREEMENT

The FireMed Ambulance Membership Program is a voluntary service available to the residents of the North Douglas County Fire & EMS (NDCFEMS). It is operated by the NDCFEMS. Members receive emergency ambulance service as noted below. Members shall pay an annual membership fee and assign to the NDCF any benefits for ambulance services in the insurance policies, third party recovery, or other medical benefits they may have. FireMed is not insurance but will provide ambulance services through the NDCF. The NDCF will bill insurance or medical benefits and are entitled to all medical benefits. FireMed is in excess of any medical benefits members may have.  Members authorize the release of medical information for the purpose of ambulance billing only. Should a person included under this membership receive payment directly from insurance, third party recovery, or other medical benefits for ambulance services rendered by the NDCFEMS, they will immediately forward such payment to the NDCFEMS. Members agree to cooperate in any efforts to bill and collect from insurance, third party, or other medical benefits for services rendered, including the execution of documents or claim forms. FireMed membership is not solicited from persons who receive welfare, Medicaid or the Oregon Health Plan medical benefits.  Any such membership constitutes a voluntary contribution only.  Membership coverage begins upon acceptance of a completed application form accompanied by the appropriate membership fee and extends to October 31.  Members, or their insurance, will be billed for any non-transport medical calls after the third call in a year's time, for the same member, at the standard aid call fee schedule. Members, or their insurance, will be billed for non-transport motor vehicle aid calls per the aid call fee schedule. Membership is non-transferable and non-refundable. Violations of the terms of agreement may result in immediate cancellation of membership and the individual will be held responsible for the full amount of ambulance charges.

DEFINITION OF MEMBERSHIP ELIGIBILITY

FireMed membership includes all persons who are permanent residents of the same single occupancy, non-commercial residence within the NDCFEMS Ambulance Service area living together as part of a family unit, but not to include mere roomers or boarders.  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 "Member".  Anyone who joins a household after this agreement goes into effect can be included under membership from the date the "Member" notifies FireMed of the addition.  Only those persons who are permanent residents of the household and are listed on the membership form at the time services are rendered are eligible for benefits.

MEMBER BENEFITS IN AREAS OUTSIDE OF LOCAL FIREMED SERVICE AREA

Member benefits may be extended to areas outside the local (home) FireMed Service Area to other FireMed participating agencies.  These benefits are limited to the terms of agreement in effect by the FireMed participating agency providing the services at the time benefits are used. Members who receive ambulance service from any other FireMed participating agency are eligible for benefits offered by that agency provided that:  1) A copy of the ambulance bill is submitted to the "home" FireMed agency within 30 days of receipt of bill, 2) the members agrees to abide by the participating agency's terms of the agreement. A current list of FireMed participating agencies is on file in the FireMed business office. NDCFEMS makes no claim as to the type, level or quality of services provided by the participating agency. Participating agencies are subject to change without notice.  

TO THE INSURANCE CARRIER

As a Firemed member, I authorize a copy of this agreement to be used in place of the original file at the FireMed office. I assign and authorize payment of insurance benefits for ambulance services for myself and/or household members directly to the NDCFEMS, according to the FireMed Terms of Agreement and itemized on claim forms. My membership will cover any applicable deductible and/co-insurance amounts. I have paid the co-payment for ambulance services rendered and expect the usual and customary ambulance reimbursement on my behalf to be sent directly to the NDCFEMS.