Bill Payment and Membership Payment

Service to March 31, 2006

TERMS OF THE MEMBERSHIP:

Hollidaysburg American Legion Ambulance Service Members are entitled to unlimited emergency medical services that meet medical necessity guidelines. Medical necessity is established when the patient could no be transported by any other means without endangering their health. If the patient could be transported by a wheelchair van, car, taxi, etc., then medical necessity does not apply.
 
The base rate for transports to hospitals outside the local area (including non-emergency transports) are also covered by the terms of the membership. Non-emergency transports may require pre-authorization by a physician and your insurance carrier.
 
When membership status (i.e. invividuals to rest home) address or any additions or deletions to the membership change, the member must notify the business office.
 
When the membership is purchased after the campaign drive ends, there will be a 30 day waiting period for all non-emergency transports.

Services not covered- Round trip transports for treatment and/or special services at other facilities while you are a patient in the hospital and/or transportation to a facility when the same services was available at a closer facility.

Failure to comply with the terms of the membership may void all future benefits of your membership.
 
This membership authorizes the Hollidaysburg American Legion Ambulance Service to bill and receive any available funds due from Medicare or other insurance carriers for services rendered. Mileage charges outside of the service area are not covered by the membership and may be billed to the member if not covered by insurance.

AUTHORIZATION

  I/WE AUTHORIZE THAT PAYMENT OF AUTHORIZED MEDICARE BENEFITS OR OTHER INSURANCE BENEFITS BE MADE ON MY/OUR BEHALF TO HOLLIDAYSBURG AMERICAN LEGION AMBULANCE SERVICE INC. (HEREAFTER KNOWN AS H.A.L.A.S.) FOR ANY AMBULANCE SERVICES PROVIDED TO ME/US BY H.A.L.A.S.  I/WE AUTHORIZE ANY HOLDER OF MEDICAL INFORMATION OR DOCUMENTATION ABOUT ME/US TO RELEASE TO THE CENTERS FOR MEDICARE AND MEDICAID SERVICES AND ITS CARRIERS AND AGENTS, AS WELL AS TO H.A.L.A.S. ANY INFORMATION OR DOCUMENTATION NEEDED TO DETERMINE  THESE BENEFITS OR BENEFITS PAYABLE FOR ANY SERVICES PROVIDED TO ME/US BY H.A.L.A.S. NOW OR IN THE FUTURE.