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Membership Information
AMBULANCE TRANSPORT SERVICE, INC..
Yearly Membership Application
EMERGENCY! It can happen to anyone at any time. That's why at Ambulance Transport Service, Inc., we have been providing top quality emergency medical care to residents of Jefferson County for more than 20 years. ATS operates 10 paramedic units, 1 intermediate unit, 1 specialty unit equipped with auto extrication and diving equipment, and 1 wheelchair van. Our paramedic units are equipped with the latest state of the art equipment and medications for all medical, cardiac, and trauma emergencies for pediatrics or adults. Our personnel receive continuing education upgrading their knowledge and skills to better serve the residents. We are also affiliated with the American Heart Association as a Community Training Center. To decrease our response times to your emergency, we operate three stations to cover Jefferson County. Why buy a membership? As a member you are entitled to transports by an ambulance to the nearest hospital for emergencies, and transports from the hospital by an ambulance when deemed medically necessary by your physician. We also transport to other facilities by our wheelchair van for a member rate of $10.00 one way, plus mileage charges outside Jefferson County for $1.00 per mile. The regular cost of one ambulance call could pay for a membership for approximately 10 years. So please print out this application for membership and return it with your check or money order to us today, because an EMERGENCY could be only seconds away! Date mailed to ATS__________________ Check#_________________ Amt. $___________________
Keep this portion for your records.
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Send this portion with check or Money Order payable to: ATS, 1407 N. Hutchinson, Pine Bluff, AR 71602
247-3792 or 1-888-235-1683 (office)______ Individual $30.00 247-1804 (Emergency- Jefferson County) ______ Family $40.00 ______ Senior Citizen (age 65 or older) $15.00 If you are a Medicaid recipient, you do not need this membership. We accept Medicaid as payment in full. You may still choose ATS as your ambulance provider. List your name and each family member (spouse, unmarried children under age 21 living at home). Name_________________________________ Name________________________________ SSN#_________________ Birthday____/____/____ SSN#_________________ Birthday____/____/____ Insurance Company 1____________________ Insurance Company_____________________ Policy#______________ Group#___________ Policy#_________________ Group#__________ Insurance Company 2___________________ Insurance Company 2_____________________ Name________________________________ Name___________________________________ SSN#_________________ Birthday____/____/____ SSN#__________________ Birthday____/____/____ Insurance Company 1____________________ Insurance Company 1_______________________ Policy#______________ Group# __________ Policy#_________________ Group#___________ Insurance Company 2____________________ Insurance Company 2________________________ Address to Send Renewal Notice and Information:____________________________________________________________________ Phone Number:___________________________
Membership Contract
I, the undersigned, hereby authorize payment, directly to Ambulance Transport Service, Inc., of the ambulance benefits otherwise payable to me, but not to exceed the regular charges for this type of service. I understand that I am responsible to Ambulance Transport Service, Inc., for charges not covered by insurance or this membership and do hereby guarantee payment of the bill within 15 days. I also understand that this membership permits Ambulance Transport Service, Inc. to collect directly from any third party agency, whatever benefits may be available, at no charge to me (Medicare, BCBS, Car Insurance, etc.) I will furnish the ambulance service with any information needed to assist them in obtaining these benefits. If benefits are paid directly to me. I will forward them to the ambulance service to be applied to the services that I received._________________________________________ _________________________ Signature Date
***THIS IS NOT AM INSURANCE POLICY!***
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