Generic Terms of Agreement

Download a sample of the Terms of Agreement

Definition:

FireMed is a voluntary ambulance membership program operated by the Fire Department. FireMed is not insurance. All coverage for services is in addition to any medical benefits members may have. FireMed will bill insurance or other coverage for ambulance services costs that members may have incurred and FireMed is entitled to all benefits paid by insurance for ambulance services rendered, up to the total dollar amount of services incurred.

Membership Benefits:

Membership covers applicable patient out-of-pocket expenses for medically necessary emergency and non-emergency* ambulance care and transportation provided by FireMed within the ambulance service areas. *Non-emergency ambulance services are covered only to approved destinations, when medically necessary, and with prior physician authorization and documentation.

Membership Benefits Outside of Local Service Area:

Other participating reciprocal agencies may extend member benefits to areas outside our ambulance service area. These benefits are limited to the terms of agreement in effect by the participating agency providing services at the time benefits are used. Members who receive ambulance service from any other participating agency are eligible for benefits offered by that agency. The member agrees to abide by the participating agency's terms of agreement. A current list of participating agencies is on file in the FireMed business office and on our website. FireMed is not responsible for the type, level, or quality of services provided by a participating agency nor is FireMed financially responsible for any costs or charges incurred by a member from any other ambulance provider. FireMed is not responsible for the withdrawal of participating reciprocal agencies. Participating agencies are subject to change without notice.

Member Responsibilities:

Members pay an annual membership fee and will assign and transfert to FireMed all rights and reimbursements for ambulance services from all insurance policies, plans, or other benefit programs members may have, including all rights in any claim or third party recovery, up to the total dollar amount of services incurred, where ambulance services were provided by FireMed. Should any person covered under this membership receive any payment for ambulance services rendered by FireMed, they will immediately forward such payment to FireMed. Members authorize the release of medical and other information by or to FireMed as necessary for ambulance billing. Members agree to provide, when requested, any or all information concerning insurance policies, plans, third party recovery, or other benefit programs they may have, and will cooperate and assist as necessary in any efforts to bill and collect such ambulance reimbursements, including the completion and submission of documents or claim forms.

Membership Eligibility:

Residents of the FireMed ambulance service areas are eligible to join by properly completing an enrollment application available from FireMed and by paying the appropriate annual membership fee. FireMed household membership includes all persons who are permanent residents of the same single-family occupancy, non-commercial residence, within the FireMed ambulance service areas, living together as dependants of a family unit and who are listed as such on your income tax returns, including domestic partners, but not to include mere roomers or boarders. Membership benefits include dependant household members living in substitute care (e.g. nursing homes) in the FireMed ambulance service areas. Others not included in this definition are required to obtain their own separate membership. The first person listed on the application form is called the "Primary Member." Anyone who joins a household after the membership goes into effect can be included under the membership from the date the "Primary Member" notifies FireMed of the addition. Only those persons who meet the membership eligibility requirements AND are listed in the membership record at the time services are rendered are eligible for benefits.

Duration:

Membership coverage begins upon acceptance of a properly completed application form with payment and extends to our annual closing date.

To the Member's Insurance Carrier (for members with insurance):

As a FireMed member, I authorize a copy of this agreement to be used in place of the original on file at the FireMed office. I assign and authorize payment of benefits for ambulance services directly to FireMed, according to the FireMed terms of agreement and as itemized on claim forms. My membership fee covers any applicable deductible, co-insurance, or co-payment and I expect the usual and customary ambulance reimbursement on my behalf to be sent directly to FireMed.

Disclaimer:

FireMed reserves the right to add, modify, or delete any of the program terms and conditions completely or in part. All interpretations of the membership terms and conditions shall be at the sole discretion of FireMed. Membership is non-transferable and non-refundable. Persons who receive welfare, Medicaid, Department of Medical Assistance Programs, or Oregon Health Plan medical benefits need not be members in order to have full coverage for services covered under these programs. Any such membership constitutes a voluntary contribution only. Violations of the terms of agreement may result in membership revocation, forfeiture of benefits associated with membership and an obligation to pay all balances in full.

FireMed Plus - Air Ambulance Option:

If you or a family / household member uses Life Flight Network emergency air transport under medically necessary circumstances, Life Flight Network will accept an insurance settlement (if any) as payment in full. Such transports are also covered for members transported by a reciprocal provider. Related ground ambulance transport is covered when provided by a FireMed network reciprocal provider. The Air Ambulance Network flies patients on the basis of medical need, not membership status...

NOTICE: By sending your check, you authorize FireMed to use the information on your check to make a one-time electronic debit from your account. Your original check will be destroyed once processed, and you will not receive your cancelled check back. If you do not wish to participate in this check conversion program or have further questions regarding this process please call your local FireMed Provider - Membership Services: Monday-Friday, 8-5 pm. Thank You.