In consideration and payment of the $69 SEMS MEMBERSHIP fee, I hereby assign to SEMS all ambulance benefits that any covered household member or I may otherwise be entitled to receive from any insurance or other third-party payor for services provided by SEMS. I understand that SEMS will accept this assignment and file ambulance insurance claims for each covered person. SEMS is entitled to receive payment from all insurance or other third-party payors up to the amount of SEMS’s usual charges.

SEMS will accept the insurance or third-party payor's approved payment for emergency and non-emergency transport services. The SEMS MEMBERSHIP will cover the cost of deductibles and co-payments, and I will not be billed by SEMS for these expenses. If no insurance or other third-party payor benefits are available or if the insurance company or other third-party payor denies payment for services, I understand that I will be responsible for payment of said services at the reduced SEMS MEMBERSHIP rate, which is $100 for local emergency base rate; 50% reduction for non-emergency base rate; and 50% reduction for out-of-town mileage. I agree to provide SEMS with any valid insurance and/or third-party payor information, pertaining to me or any covered member of my household, within 60 days of receiving

ambulance service. In addition, I agree to furnish any information requested by my insurance company in order to facilitate payment of ambulance claims for me or any covered member of my household. Should I receive direct payment from insurance or a third-party payor for SEMS ambulance services, I agree to immediately forward the full amount received by me to SEMS. I understand that a violation of these terms voids the membership retroactively to the date of purchase. Non-transport services are not a covered benefit under this membership. SEMS MEMBERSHIP is non-refundable and non-transferable. I understand that this is a voluntary subscription, and if unable to purchase a membership it will not affect my ability to receive quality ambulance service. Patients are treated with equal care, regardless of membership status.

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MEMBERSHIP becomes effective at time of purchase and expires June 30, 2025.

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