Air Methods Membership Agreement Terms & Conditions
Membership applies only to me, unless I choose to enroll in a “Family Membership.” If I enroll in a Family Membership, membership will apply to me, my spouse, my children under the age of 26, and my dependent children of any age who are incapable of supporting themselves due to a mental or physical disability. “Children” includes natural and adopted children who reside in a state where Air Methods Advantage provides coverage, stepchildren who live with me, and children for whom I have legal guardianship.
If I receive a medically necessary air medical transport by an Air Methods Corporation wholly-owned subsidiary such as Rocky Mountain Holdings, LLC; Mercy Air Service, Inc.; LifeNet, Inc.; or Tri-State Care Flight, LLC(collectively, “Air Methods”), Air Methods will bill my health insurance and any other responsible third party payer including, but not limited to, automobile insurance (collectively, “Insurance”). 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 for the transport that occurs during the time my membership is in effect. 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, I hereby assign and transfer to Air Methods all benefits payable by Insurance to or for my benefit, or the benefit of my spouse and/or children as included in my membership, for services rendered.
Membership covers only medically necessary air medical transports by Air Methods to the closest appropriate hospital in Air Methods’ service area. I am responsible for the cost of any transports that are determined to be not medically necessary.
I understand that under some circumstances, Air Methods may not be available to transport me. This may be due to weather conditions, maintenance, commitment of the aircraft to another transport, governmental market restrictions, FAA restrictions, Air Methods’ absence from the local market, weight and balance 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.
Membership becomes effective three (3) days after receipt of a completed application and payment in full. There is no waiting period for membership renewal.
I understand that memberships with Air Methods Advantage are non-refundable and non-transferable.
I agree to notify Air Methods Advantage within five (5) business days of any change in my health Insurance or the health Insurance of any family members covered by my membership. I understand that automobile insurance, home owner’s insurance, etc., are not considered health Insurance.
I certify to Air Methods Advantage that I am not covered by military insurance, including TRICARE, CHAMPUS, VA, etc.
I certify to Air Methods Advantage that I am not a Medicaid beneficiary.
I understand that Air Methods Advantage is not an insurance product. I certify that I am the individual applying for membership and am the legal representative for my spouse and children listed below, and that I am duly authorized by them to execute this application and accept its terms and conditions on their behalf. I certify that the information in this application is accurate.
BEFORE YOU PURCHASE: If you are currently enrolled in a Health Maintenance Organization (HMO) or other health insurance, the benefits provided by an ambulance plan may duplicate the benefits provided by your HMO or other health insurance. If you have questions regarding whether your HMO or other health insurance offers benefits for ambulance services, you should contact that other company directly.
WARNING: This ambulance plan is not an insurance program. It will not compensate or reimburse another ambulance company that provides emergency transportation to you or your family. This may occur when the 911 Emergency Systems have independently determined that another company can provide more expeditious service or it is next in the rotation to receive a call. This might also occur when the ambulance plan is unable to perform within a medically appropriate time frame due to mechanical or maintenance problems or being on another call. Initials: __________.
COMPLAINTS: For complaints regarding this Ambulance Plan, first attempt to call the plan toll-free at 855-877-2518. If the Ambulance Plan fails to resolve the complaint to your satisfaction, contact the Department of Managed Health Care at 1-888-466-2219. The Department’s website is http://www.healthhelp.ca.gov. You may obtain complaint forms and instructions online.”
OPERATING UNDER CONDITIONAL EXEMPTION: This Ambulance Plan is operating pursuant to an exemption from the Knox-Keene Health Care Service Plan Act of 1975 (Health and Safety Code section 1340 et seq.).”