Danville Rescue Squad

Subscription Program Membership Application

P O Box 255, Danville VT 05828

Period Covered: January 1 – December 31 Year: ______ Cost: $40.00

Please answer all questions to insure proper credit and recording

SUBSCRIBER INFORMATION

Your Name: Last

First

DOB

Sex

SSN

Your Mailing Address

Town

Zip

Phone

Your Physical (911) Address

Membership Status – Circle NEW RENEWAL

INSURANCE INFORMATION

Your Primary Medical Insurance Company Name

Phone #

Policy #

Group #

Your Secondary Medical Insurance Company Name

List all other persons permanently residing with you who would be covered by this membership

Name: Last

First

DOB

Sex

SSN

Insurance information if different

TERMS AND CONDITIONS: Membership in the Danville Rescue Squad Subscription Program provides the subscriber and any individual permanently residing in the same household to receive a) medically necessary emergency ambulance transports to the Northeastern Vermont Regional Hospital (NVRH) and b) three medically necessary non-emergency local transfers, all without additional out of pocket expense, beginning January 1, or on receipt of your application and payment if mailed after this date, and ending December 31 of the same year. Danville Rescue Squad reserves the right to bill and receive payment from your insurance carrier. Payment made directly to you by your insurance carrier for services covered under this agreement must be forwarded to Danville Rescue Squad. Membership cannot be prorated and must be paid and active in order for these conditions to apply. If you are transported by CALEX Ambulance, or Lyndon Rescue, Inc., they will honor current membership in the program under the same conditions.

Authorization for Billing and Release of Information: I Authorized Danville Rescue Squad to submit all charges to federal or commercial insurance carrier(s) and authorize federal or commercial insurance carrier(s) to make direct payments to Danville Rescue Squad. I further authorize the release of all medical records to federal or commercial insurance carrier(s), now or in the future, to expedite or complete claims or verify future eligibility for claim processing. I request that payment for services rendered by Danville Rescue Squad be made directly to Danville Rescue Squad. I have read and agree to the terms and conditions of membership stated above.

Subscriber Signature

Spouse / Other Party

Please enclose check payable to Danville Rescue or to pay by credit card, complete the below:

VISA / Master Card

Card #

Exp Date

Credit Card Authorization

For Office Use Only

Payment Received on

Check #

Status updated in Database on

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