OmniAdvantage Membership Agreement

By enrolling in the OmniAdvantage membership program, I agree as follows:

• Membership applies to me, my spouse/partner and dependent children under the age of 26 who live with us and are insured, as listed on the application below.
• If I receive an air medical transport by Air Methods Corporation, Air Methods Corporation will bill my insurance or other responsible third party payer (collectively, “Insurance”). Air Methods Corporation will accept the amount paid by my Insurance as payment in full for any medically necessary transport. The membership fee constitutes prepayment for any deductible, copayment or other out-of-pocket expense not covered by my insurance, so I will be relieved of any out of pocket expense following transport. Subject to the foregoing, I acknowledge that I am responsible for payment for ambulance services rendered to me.
• In the event I am transported by Air Methods Corporation, I hereby assign and transfer to Air Methods Corporation all benefits payable by Insurance to or for my benefit, or the benefit of my spouse or dependents that are named as enrollees on my membership, for services rendered.
• Membership covers only medically necessary air medical transports by Air Methods Corporation to the closest appropriate hospital. Medical necessity is determined by my Insurance, based on information from the attending physician. I am responsible for the cost of any transports that are determined not to be medically necessary.
• I understand that under some circumstances, Air Methods Corporation may not be available to transport me. This may be due to weather conditions, maintenance, commitment of the aircraft to another transport, FAA restrictions, governmental market restrictions or other factors. I understand that membership does not cover the cost of any transports rendered by air or ground providers other than Air Methods Corporation.
• Membership becomes effective three (3) days after receipt of a completed application, accompanied by a payment of the membership fee. There is no waiting period for membership renewal.
• I agree to notify OmniAdvantage within five business days of any change in my Insurance or the Insurance of any family members enrolled in OmniAdvantage. Loss of Insurance will result in automatic loss of membership.
• Neither I, nor the family members named below, are Medicaid enrollees.

I understand that OmniAdvantage membership is not an insurance product. I certify that I am the individual applying for membership and am the legal representative of my spouse and dependent children listed below, and am duly authorized by them to execute this application and accept its terms and conditions on their behalf.

A copy of member(s) insurance card must be submitted with application. If spouse/partner and dependents listed above have different insurance, submit a copy of their card.

If you have questions about OmniAdvantage call (855) 877-2518.