Care Plan: Become a Member

Rockford Ambulance Care Plan
Membership Terms and Conditions

Membership includes emergency and non-emergency ambulance and paramedic services provided within a 50 mile radius of the Rockford Ambulance office located at 8450 Shaner Ave., NE, Rockford, MI 49341 by Rockford Ambulance, Grand Rapids Township Ambulance and its affiliates. For all emergency and non-emergency services medically necessary into the hospital provided within that 50 mile radius, there will be no out-of-pocket expenses to you during the contract period.

Membership also includes medically necessary, non-emergency stretcher ambulance transportation from the hospital provided within a 50 mile radius of the Rockford Ambulance office located at 8450 Shaner Ave., NE, Rockford, MI 49341. Twenty-four hour advance scheduling is required, and physician authorization of medical necessity is required for all non-emergency services. Call 911 to request emergency service. Please note that emergency calls have first priority over non-emergency calls.

You understand that as the patient, you are normally responsible for the payment of services. However, as a member of the Rockford Ambulance Care Plan, Rockford Ambulance will accept you available insurance reimbursement as payment in full. Rockford Ambulance will collect any available reimbursement for services rendered directly from any of your insurance companies or other medical benefit providers in addition to the membership fee. You agree to cooperate with the claim submission to your insurance companies and/or medical benefit providers and to provide any correspondence regarding any claim to Rockford Ambulance if requested. You further agree to submit any insurance reimbursement you receive for Rockford Ambulance directly to Rockford Ambulance. Failure to fully cooperate with Rockford Ambulance and abide by these terms will result in the termination of your membership and make you responsible for any unpaid expenses.

You understand that your initial membership payment covers your household from the time Rockford Ambulance receives the signed contract and full payment of the $39 and continues until the following September 30. Membership in Rockford Ambulance Care Plan is non-transferrable, and non-refundable. For Federal Income Tax purposes, the membership fee is not deductible as a charitable contribution, but may be eligible for deduction as an itemized medical expense. Rockford Ambulance does not solicit from persons who receive welfare medical benefits, and membership constitutes a voluntary contribution only. This is not an application for an insurance policy. You request that payment of authorized Medicare/insurance benefits be made on your behalf to Rockford Ambulance for any services furnished by Rockford Ambulance. You authorize any holder of medical information about you to be released to the health care finance administration, its agents, and carries as well as Rockford Ambulance that may be necessary to determine benefits payable for services by Rockford Ambulance. You agree that you will sign any HIPPA authorization required. You agree to immediately remit to Rockford Ambulance all payments you receive from your insurance companies or any such source whatsoever for services provided to me by Rockford Ambulance and/or it affiliates.

IMPORTANT: MEMBERSHIP WILL NOT BECOME EFFECTIVE UNTIL ROCKFORD AMBULANCE RECEIVES A SIGNED CONTRACT AND FULL PAYMENT OF $39. All household members must be on record with Rockford Ambulance to receive benefits. Wheelchair transportation service is not covered by the Rockford Ambulance Care Plan. However, members are offered the service at a discounted rate.

The Rockford Ambulance Care Plan Membership Service Agreement only applies to those services which are provided within a 50 mile radius of the Rockford Ambulance office located at 8450 Shaner AVE., NE, Rockford, MI 49341.