Primary Membership Care Application

Membership Application

Please Note: 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.

Primary Applicant Information
                        Additional Insurance Information - Primary Applicant
                                Membership Agreement & Authorization

                                I acknowledge that my insurance provider or I am 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 states 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 Members 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 will be immediately delivered 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.

                                  By submitting this form, 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 party 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 Ambulance all information necessary to file a claim for payment under my insuance policy, plan or program, or from any third payor.

                                  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.


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