Millcreek Paramedic Service Membership

As a member of Millcreek Paramedic Service, I understand that I will request that payment of authorized Medicare/Insurance benefits be made on my behalf to Millcreek Paramedic Service for any ambulance services furnished to me by Millcreek Paramedic Service. I will authorize any holder of medical information about me to release to all third party health and medical benefits payors and their agents and carriers as well as to Millcreek Paramedic Service, any information needed to determine these benefits or benefits payable for related services or any services provided to me by Millcreek Paramedic Service now and in the future.I will authorize payment for these benefits to be made directly to Millcreek Paramedic Service. I will agree to pay immediately to Millcreek Paramedic Service, all payments sent directly to me from either the insurance company or other medical benefit providers.

I understand that while the patient is responsible for payment for services, my Millcreek Paramedic Service membership fee will cover my deductibles or co-payments when emergency transportation is deemed medically necessary by my insurance company according to CMS (Medicare/Medicaid) guidelines.

I will cooperate in any way with claim submission to my medical benefit providersand to provide any correspondence regarding my claim(s) to MPS, if requested. You have the right to elect not to receive any further fundraising communication from Millcreek Paramedic Service.

I understand that “Family Membership” includes everyone who is claimed on my family’s head of household tax return.

I understand that non-emergency wheelchair transportation services are NOT a covered benefit, and fees will apply.

I understand that my MPS membership also includes medically necessary, non-emergency ambulance transportation, when provided by MPS. Twenty-four hour advance notice is requested for scheduling non-emergency transports. Physician Authorization of medical necessity is required for all non-emergency services.

MPS reserves the right to change scheduled transports due to emergency requirements. An MPS membership is non-transferable and non-refundable.

An MPS membership fee is not tax deductible as a charitable contribution, but may be eligible as an itemized medical deduction. An MPS membership is not an insurance policy. I understand a 2018-2019 MPS one year membership is valid through November 30, 2019 and a two year membership is valid through November 30, 2020. This program is not applicable to Medical Assistance beneficiaries.

Membership is not a contract for provision of services at any specific time and, as with any ambulance company, services are subject to availability.

Service may be provided by a mutual aid company during a period in which MPS may be unavailable.

Membership does not apply for 911 calls where a patient refuses care and/or transport and signs a refusal form.

Membership does not apply for non emergency wheelchair van or medical taxi transports.

The membership program may be subject to modification without prior notice.

All discounts must be taken at the time of purchase.