JEANNETTE E.M.S., INC.
Sept 1, 2016 - Aug 31, 2017
SUBSCRIPTION APPLICATION

NAME_______________________________________________________________________________________
               LAST                                                 FIRST                                                                                M.I

ADDRESS:_________________________________________________________________________________
                HOUSE #     STREET                                            CITY                             STATE                   ZIP

TELEPHONE NUMBER____________________________________________________________________________________

PLAN APPLYING FOR:

( )HOUSEHOLD $70.00

( )SINGLE $45.00

( )BUSINESS $___________

( )MORTGAGE FUND
DONATION $___________

TOTAL ENCLOSED $___________

( ) PAID BY CASH ( ) PAID BY CHECK ( )PAID BY MONEY ORDER
CHECK #______________

PLEASE PROVIDE INFORMATION ON PAGE 2 FOR YOU AND YOUR FAMILY MEMBERS.

I REQUEST THAT PAYMENT OF ANY AUTHORIZED INSURANCE BENEFITS BE MADE IN MY BEHALF TO THE JEANNETTE E.M.S., INC. FOR ANY SERVICES FURNISHED TO ME OR ANY FAMILY MEMBER LISTED ON THIS FORM BY THIS HEALTH CARE PROVIDER. I AUTHORIZE ANY HOLDER OF MEDICAL INFORMATION ABOUT ME OR MY FAMILY MEMBERS LISTED ON THIS FORM TO RELEASE TO THE HEALTH CARE FINANCING ADMINISTRATION AND IT'S AGENT'S ANY INFORMATION NEEDED TO DETERMINE THESE BENEFITS OR THE BENEFITS PAYABLE FOR RELATED SERVICES.

I UNDERSTAND THAT JEANNETTE E.M.S, INC. RESERVES THE RIGHT TO THIRD PARTY BILL FOR SERVICES RENDERED TO ME OR MY FAMILY MEMBERS LISTED ON THE OTHER SIDE.

___________________________________________________________________________
APPLICANT'S SIGNATURE                                                                                DATE



 

 

 

Page 2

SUBSCRIBER AND FAMILY MEMBERS

NAME

DATE OF BIRTH

TYPE OF INSURANCE

MEDICARE /INSURANCE I.D. #

SECONDARY INSURANCE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

KEEP THIS PAGE FOR YOUR RECORDS

RECEIPT

DATE RECEIVED:_______________________ RECEIVED BY: __________________

AMOUNT RECEIVED: ___________________________ ( )CASH ( )MONEY ORDER ( ) CHECK #__________________

THIS IS TO CERTIFY THAT:

__________________________________________________

IS A SUBSCRIBER TO JEANNETTE E.M.S., INC. FOR THE SUBSCRIPTION YEAR
September 1, 2016 TO August 31, 2017

EMERGENCY DIAL 911 * TRANSFER PHONE 724-523-5501 *
BUSINESS OFFICE 724-523-5503


RULES


THE MEMBERSHIP FEE FOR THIS SERVICE INCLUDES EMERGENCY SERVICE
EXCEPT IN EMERGENCY, AUTHORIZATION FROM YOUR PHYSICIAN IS REQUIRED TO USE AN AMBULANCE
DISCOUNT RATES FOR NON-INSURANCE TRANSPORTS
RULES AND RATES ARE SUBJECT TO CHANGE WITHOUT NOTICE
ALL NON-EMERGENCY TRANSPORTS ARE SUBJECT TO MILEAGE CHARGES
WHEELCHAIR VAN TRANSPORTS ARE NOT PART OF YOUR SUBSCRIPTION.