Subscription & Terms
"I hereby apply for a subscription to St. Marys Area Ambulance Service, Inc. (SMAAS) and agree to the following terms and conditions:
SMAAS, upon receipt of a properly completed subscription application and the appropriate fees as indicated on the subscription application, entitles the holder to medically necessary EMERGENCY AMBULANCE SERVICE. THE SUBSCRIBER IS ENTITLED TO UNLIMITED USE OF St. Marys Area Ambulance emergency services within the City of St. Marys, based upon availability of available resources, at no further "out of pocket" expenses to the subscriber. The subscription is effective, upon receipt and acceptance of my subscription and the assignment, expires annually on April 30th.
The FAMILY PLAN includes husband, wife, and unmarried children living at home under 18 years of age. Full time college students up to 24 years of age are included in the Family Subscription.
The INDIVIDUAL SUBSCRIPTION covers the individual named on the subscription card only. This subscription is effective upon receipt by the St. Marys Area Ambulance Service, and expires annually on April 30, following receipt.
This subscription also includes access to pre-scheduled NON-EMERGENCY AMBULANCE SERVICE which is determined to be medically necessary by the St. Marys Area Ambulance Service Management. Non-emergency service is subject to availability, staffing, scheduling, and equipment constraints. This is an additional service, but not a contractual obligation between St. Marys Area Ambulance and the subscriber. Emergencies always have priority. 24-hour notice and Physician authorization may be required for these non-emergency services.
The subscriber will be responsible for all charges associated with non-emergency ambulance services which are provided in good faith but is later determined that the charges are not covered by the subscriber's insurance for any reason.
Subscribers are also responsible to provide full cooperation with St. Marys Ambulance's designated billing representatives in their effort to collect any and all reimbursements associated with the provision of emergency medical services, non-emergency ambulance services or alternate medical transportation services. Subscribers are also required to remit to St. Marys Ambulance Service any and all reimbursement immediately upon receipt from any source including commercial or government agencies or any other third party insurance carrier or program for services provided under the terms and conditions of the subscription program. St. Marys Area Ambulance reserves the right to initiate legal action against the subscriber to recover any and all reimbursement received by the Subscriber related to the provision of subscription related services. Any and all costs, fees and interest associated with the legal action necessary to recover said reimbursement will also be the responsibility of the subscriber assessed.
Subscribers will be offered discounted rates for use of alternative medical transportation including wheelchair van services for medical transports. Wheelchair van service is subject to availability, staffing levels, scheduling, and equipment constraints. A minimum of 24 hour notice must be given for a request for wheelchair van service. This subscription will provide wheelchair transportation within the City of St. Marys at a rate of $5.00 per trip. A $1.00 per mile charge will be added to any transport outside the City of St. Marys.
Solely the staff of St. Marys Area Ambulance Service or its Medical Director will make dispatching and transporting decisions regarding the acceptance of the request for pre-scheduled non-emergency related ambulance and medical wheelchair van transportation services. SMAAS's acceptance of insurance assignment for pre-scheduled ambulance service may be contingent upon the determination of my insurance that use of the ambulance was medically necessary.
A valid subscription provides supplemental financial protection for an amount, which is calculated as the DIFFERENCE BETWEEN ALLOWABLE CHARGES BY THE SUBSCRIBER'S INSURANCE PROGRAM, AND THE GROSS BILLED for medically necessary emergency or non-emergency ambulance services. This protection is also extended to subscribers who utilize St. Marys Ambulance services under the terms and conditions outlined, and have no applicable or billable coverage for medical transportation.
Subscription coverage applies only to persons who accept all terms of this agreement. This subscription is non-refundable and non-transferable.
As part of the consideration for this subscription agreement, I hereby assign to SMAAS all my rights and benefits under my hospitalization and any other applicable medical insurance or other benefits or insurance policies for service rendered to me by St. Marys Area Ambulance Service, Inc.
I authorize and direct my insurer(s) and medical benefits provider (s) to pay directly to SMAAS all sums owed for each service rendered to me. When services are rendered: I will notify my insurance as required, and provide insurance numbers and authorization needed by SMAAS to bill my insurance. SMAAS will send my bills directly to my insurer or other medical benefits provider. I agree to forward to St. Marys Area Ambulance Service any payments I receive for services rendered to me by or for SMAAS under this subscription agreement."
NOTE: This is not an insurance contract. This is not a solicitation to persons receiving medical assistance benefits.
Last Revised: January 21nd