The following are terms of the Golder Ranch EMS Membership plan (The Plan):

The Plan is available to all residents of Golder Ranch Fire District (The District)
and the family members who live in the resident’s household (provided that
they are enrolled in the plan at the time of application). The Plan covers only
MEDICALLY NECESSARY* ambulance transports provided by The District to a
hospital. Transports from the hospital to another location are not included in
The Plan.

*Medicare guidelines determine medical necessity. A Physician Certification
Statement (PCS) documenting the MEDICAL CONDITION that makes ambulance
transportation a MEDICAL necessity is required for all non-emergency trips and
may be required on emergency trips that are denied by Medicare or other third
party agencies. Pre-authorization must be secured prior to non-emergency
transports for those patients whose insurance requires such authorization. The
Plan covers only that portion of the cost of transport not covered by a patient’s
health insurance or other available sources of payment. As a courtesy to The Plan
member, The District will submit a claim for payment to the member’s insurance
for each ambulance transport.

Plan members agree to assist The District in collecting payments from insurance
providers, including but not limited to promptly providing necessary information
and signatures for submission of claims to insurance providers and taking other
steps necessary or reasonably required to facilitate payment to The District. If the
Plan member receives a payment for the ambulance transport directly from their
insurance provider, the member will immediately forward such payment to The
District. Failure to remit payment to The District within five days of receipt will
result in the Member being responsible for the full cost of the transport pursuant
to The District’s fee schedule in effect at the time of the Member’s ambulance
transport.

The Plan membership will be upon receipt of full payment together with a
signed membership agreement. The Membership fee is non-refundable and
non-transferable. The undersigned member requests that payment of authorized
benefits be made on my behalf to:

Golder Ranch Fire District | 1600 E. Hanley Blvd. | Oro Valley, AZ 85737
Direct 520-825-5902 | Fax 520-825-5985

The undersigned member authorizes any holder of medical information or
documentation about the member to release any information or documentation
needed to determine these benefits or benefits payable for related services
provided by The District now or in the future.

NOTICE: In the event your check is dishonored or returned for any reason, you
authorize us to electronically (or by paper draft) re-present the check on your bank
account for the collection of the amount of the check plus any applicable fees as
permitted by law. THE USE OF A CHECK FOR PAYMENT IS YOUR ACCEPTANCE OF
THIS AGREEMENT.

By submitting this form, I agree to the terms and conditions listed.

Golder Ranch EMS Membership is pre-paid service program offered by Golder Ranch Fire District. At no time will you be denied emergency medical services or transport based on insurance status or ability to pay.