Claim Mailing Address definition
Claim Mailing Address. City: State: Zip Code: Dependent Contact Information (Relationship to Primary Contact: ) Name: Date of Birth: -_ - Your name must match your primary insurance card exactly MM DD YYYY Sex: ☐ Male ☐ Female Social Security Number Primary Insurance Carrier Name: Policy/Subscriber/Insured #: Group #: Claim Mailing Address: City: State: Zip Code: Secondary Insurance Carrier Name: Policy/Subscriber/Insured #: Group #:
Claim Mailing Address. City: State: Zip Code: The Arizona Fire & Medical Authority (AFMA) Ambulance Membership Program (AMP) is offered to Authority residents as an alternative to paying out of pocket costs for AFMA provided medically necessary ambulance transport service. With an ambulance membership, your insurance company will be billed after you utilize our transport service. The membership fee alleviates the member’s liability for cost-sharing amounts. If your medical insurance does not require you to pay a co-pay and/or deductible for ambulance transportation, this program would not be beneficial to you. Residents are strongly encouraged to check with your medical insurance company to verify if a co-pay and/or deductible is required. The membership program is not an insurance policy. 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. If any member of the household currently has health insurance or Medicare, then this subscription agreement must be signed by the health insurance policyholder. Membership is nontransferable and nonrefundable. By submitting this subscription agreement, I hereby acknowledge that I have read, understand, and consent to the terms of the agreement outlined on all pages of this form/agreement. I acknowledge having accurately completed the information on this form.
Claim Mailing Address. City: State: Zip Code: The Arizona Fire & Medical Authority (AFMA) Ambulance Membership Program (AMP) is offered to Authority residents as an alternative to paying out of pocket costs for AFMA provided medically necessary ambulance transport service. With an ambulance membership, your insurance company will be billed after you utilize our transport service. The membership fee alleviates the member’s liability for cost-sharing amounts. If your medical insurance does not require you to pay a co-pay and/or deductible for ambulance transportation, this program would not be beneficial to you. Residents are strongly encouraged to check with your medical insurance company to verify if a co-pay and/or deductible is required. The membership program is not an insurance policy.