2007 Subscripition information

BOTTOM OF THE PAGE IS A MAIL IN SUBSCRIPITION FORM

Highlights About Your Subcription:

• We reserve the right to bill your insurance. If you receive the money directly from your insurance, you are still responible to forward that to us.

• Your subcription covers reimbursable, medically necessary (as deemed by you physician) ambulance transports.

• If you have an H.M.O. and it requires you to precertify before utilizing an ambulance, that is your responsibility. If a claim is denied it was not authorized, you will be reponsible for the bill.

• Having a subscription will allow us to accept what your insurance pays as payment in full, with the exception of deductibles.

• Access to our wheelchair van and invalid coach (reduced cost does apply).

• By Federal Law we are not permitted to write off insurance deductiable. We reserve the right to bill third party payers. Your subscription is effective immediatley and will expire on February 28, 2007

911 Designated Areas Serving All:

ADAH, ALLISON, BRIER HILL, CARDALE,CHALK HILL, CHESTNUT RIDGE, CONNELLSVILLE, DAWSON, DICKERSON RUN, DUNBAR, FAIRBANK, FARMINGTON, FLATWOODS, GIBBON GLADE, GRINDSTONE, HIBBS, KEISTERVILLE, LECKRONE, LEISENRING, LEMONT FURANCE, MASONTOWN, McCLELLANDTOWN, MERRITTSTOWN, MILL RUN, MT. BRADDOCK, NEW SALEM, NORMALVILLE, OHIOPYLE, REPUBLIC, RONCO, SMOCK, SOUTH CONNELLSVILLE, VANDERBILT, WALTERSBURG,

Serving Rural Route Areas of:

ACME, BROWNSVILLE, CHAMPION, EAST MILLS BORO, ISBELLA, MARKLEYSBURG, MASONTOWN, MT. PLEASANT, PERRYOPOLIS, SCOTTDALE, UNIONTOWN, WEST LEISENRING

So sign-up now...This subscription could save you hundreds of dollars a year...DON'T WAIT...Return this form today!

Please fill out the form below and detach and mail today to:

Make checks payable to "Fayette EMS"

FAYETTE EMS, P.O. BOX 862 CONNELLSVILLE PA 15425

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AUTHORIZATION

I authorize that payment of authorized Medicare Benefits or other insurance benefits be made on my behalf for any services furnished by this provider or supplier. I authorize any holder of medical information or documentation about me to release to the Health Care Financing Administration and its carrier and agents, as well as the health service provider, any information or documentation needed to determine these benefits or benefits payable for any services provided to me by this heath service provider now or in the future.

Signature___________________________________________date___________________

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NAME_____________________________________________________PHONE____________________________

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PLEASE LIST MEMBERS RESIDING IN YOUR HOME______________________________________________________

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SINGLE -$25. __________FAMILY-$45. _____________

BUSINESS-$100.(NON-PCH)________HONORABLE -$1000._____

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