Primary Care Membership Application

Primary Care Membership Application 2018-2019

THIS IS NOT AN APPLICATION FOR AN INSURANCE POLICY.

    Primary Care members must present a completed certificate of medical necessity to receive benefits for non-emergency transports. Primary Care provides no coverage for non-emergency transports without a certificate of medical necessity. Certificates must be completed by the patient’s physician. Transports to the doctors’s office, dentist office, physical therapy centers and pharmacies are NOT covered by Primary Care.
  • Applicant Membership Information






























  • Spouse Membership Information


























  • Children Membership Information

    Full Name and Date of Birth Of Each Qualified Child (See Membership Agreement) Under The Age Of 21 Living In Your Household Indicating Their Relationships (S=Son, D=Daughter).







  • Do you have more children then the form has allotted space for? Please enter the requested information in the space below.
  • Additional Insurance Information – Applicant


















  • Additional Insurance Information – Spouse



















    I acknowledge that my insurance provider or I are responsible for payment of ambulance service provided to me by Bartlesville Ambulance. In consideration and payment of the membership fee, I hereby assign to Bartlesville Ambulance all benefits that I (or any covered family member) may otherwise be entitled to receive from any insurance or other third-party payor for services provided under my Primary Care membership. Bartlesville Ambulance will accept this assignment as payment in full for emergency ground transport if insurance or other third-party payor coverage provides benefits for the transport. I understand Bartlesville Ambulance will file my ambulance insurance claims for each covered person and is entitled to receive payment for all insurance, Medicare or other third-party payor up to the amount of Bartlesville Ambulance’s usual charges. For non-emergency services, a Physician’s Certification Statement must be signed by the patient’s Physician. If the Physician sates the ambulance was not medically necessary and the Patient or Family wants ambulance transport, Primary Care Members will be billed 60% of the standard non-emergency charge. For Primary Care Member not qualifying for non-emergency ambulance transport, a Wheel Chair Service is available with a $5.00 reduction from the standard Wheel Chair Transport charge. Any Medicare, Insurance or other third-party payment I receive related to Bartlesville Ambulance’s services I will immediately deliver to Bartlesville Ambulance. I also understand that Bartlesville Ambulance’s services area is 20 miles radius, that the Primary Care membership is only good in the service area
  • Authorization Statement

    I authorize any holder of medical information or documentation about me or any person covered under my Primary Care membership to release to Bartlesville Ambulance and the Health Care Financing Administration and its agents and carriers any information or documentation needed to determine benefits payable for services provided to a covered person by Bartlesville Ambulance now or in the future. I hereby assign to Bartlesville Ambulance all my rights and benefits for ambulance services provided by any and all of my insurers and any third parry agencies. I further authorize my insurers and any third party agencies to pay directly to Bartlesville Ambulance whatever benefits or payments may be available for services rendered to me or my dependents by Bartlesville Ambulance.

    I agree to provide Bartlesville all information necessary to file a claim for payment under my insuance policy, plan or program or from any third payor.

  • Digital Signature

    Membership contract must be signed by the insurance holder. Membership is non-transferable and non-refundable and may be canceled upon member’s non-compliance herewith.