Common Contracts
9 similar Ambulance Membership Program Agreement contracts
AMBULANCE MEMBERSHIP PROGRAM AGREEMENTAmbulance Membership Program Agreement • July 28th, 2021
This agreement provides membership in the ambulance subscription program known as the AFMA Ambulance Membership Program. The annual membership fee per household alleviates the member’s liability for cost-sharing amounts for medically necessary ground ambulance service within the approved AFMA service area, to the nearest appropriate medical facility, for the subscriber and household members for one year, including physician-authorized, medically necessary ambulance service from a point within the AFMA approved area to a hospital within the State of Arizona. The annual fee for this program is $83.74 per household.
AMBULANCE MEMBERSHIP PROGRAM AGREEMENTAmbulance Membership Program Agreement • July 28th, 2021
This agreement provides membership in the ambulance subscription program known as the AFMA Ambulance Membership Program. The annual membership fee per household alleviates the member’s liability for cost-sharing amounts for medically necessary ground ambulance service within the approved AFMA service area, to the nearest appropriate medical facility, for the subscriber and household members for one year, including physician-authorized, medically necessary ambulance service from a point within the AFMA approved area to a hospital within the State of Arizona. The annual fee for this program is $75.00 per household.
AMBULANCE MEMBERSHIP PROGRAM AGREEMENTAmbulance Membership Program Agreement • July 28th, 2021
This agreement provides membership in the ambulance subscription program known as the AFMA Ambulance Membership Program. The annual membership fee per household alleviates the member’s liability for cost-sharing amounts for medically necessary ground ambulance service within the approved AFMA service area, to the nearest appropriate medical facility, for the subscriber and household members for one year, including physician-authorized, medically necessary ambulance service from a point within the AFMA approved area to a hospital within the State of Arizona. The annual fee for this program is $75.00 per household.
AMBULANCE MEMBERSHIP PROGRAM AGREEMENTAmbulance Membership Program Agreement • July 28th, 2021
This agreement provides membership in the ambulance subscription program known as the AFMA Ambulance Membership Program. The annual membership fee per household alleviates the member’s liability for cost-sharing amounts for medically necessary ground ambulance service within the approved AFMA service area, to the nearest appropriate medical facility, for the subscriber and household members for one year, including physician-authorized, medically necessary ambulance service from a point within the AFMA approved area to a hospital within the State of Arizona. The annual fee for this program is $88.53 per household.
AMBULANCE MEMBERSHIP PROGRAM AGREEMENTAmbulance Membership Program Agreement • July 28th, 2021
This agreement provides membership in the ambulance subscription program known as the AFMA Ambulance Membership Program. The annual membership fee per household alleviates the member’s liability for cost-sharing amounts for medically necessary ground ambulance service within the approved AFMA service area, to the nearest appropriate medical facility, for the subscriber and household members for one year, including physician-authorized, medically necessary ambulance service from a point within the AFMA approved area to a hospital within the State of Arizona. The annual fee for this program is $83.74 per household.
AMBULANCE MEMBERSHIP PROGRAM AGREEMENTAmbulance Membership Program Agreement • July 28th, 2021
This agreement provides membership in the ambulance subscription program known as the AFMA Ambulance Membership Program. The annual membership fee per household alleviates the member’s liability for cost-sharing amounts for medically necessary ground ambulance service within the approved AFMA service area, to the nearest appropriate medical facility, for the subscriber and household members for one year, including physician-authorized, medically necessary ambulance service from a point within the AFMA approved area to a hospital within the State of Arizona. The annual fee for this program is $75.00 per household.
AMBULANCE MEMBERSHIP PROGRAM AGREEMENTAmbulance Membership Program Agreement • July 28th, 2021
This agreement provides membership in the ambulance subscription program known as the AFMA Ambulance Membership Program. The annual membership fee per household alleviates the member’s liability for cost-sharing amounts for medically necessary ground ambulance service within the approved AFMA service area, to the nearest appropriate medical facility, for the subscriber and household members for one year, including physician-authorized, medically necessary ambulance service from a point within the AFMA approved area to a hospital within the State of Arizona. The annual fee for this program is $87.05 per household.
AMBULANCE MEMBERSHIP PROGRAM AGREEMENTAmbulance Membership Program Agreement • July 28th, 2021
This agreement provides membership in the ambulance subscription program known as the AFMA Ambulance Membership Program. The annual membership fee per household alleviates the member’s liability for cost-sharing amounts for medically necessary ground ambulance service within the approved AFMA service area, to the nearest appropriate medical facility, for the subscriber and household members for one year, including physician-authorized, medically necessary ambulance service from a point within the AFMA approved area to a hospital within the State of Arizona. The annual fee for this program is $83.74 per household.
Ambulance Membership Program AgreementAmbulance Membership Program Agreement • August 18th, 2020
Instructions: Add the personal information below for each member of your household. Each applicant, age 18 and over, must sign the form. By signing, you acknowledge that you have read and understand the agreement and agree to the terms of the agreement. Be sure to include payment or your payment information with your application. Mail the completed application, including this form, to:
