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 |
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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.