Passport to Care Legal Statement

Legal Statement

THIS IS NOT AN APPLICATION FOR AN INSURANCE POLICY OR SUPPLEMENT

Please read the following agreement before submitting your application.

• I understand that the membership fee ($50 single person insured annually; $65 single person uninsured annually; $60 family insured annually; $75 family uninsured annually) for the Schertz EMS Passport to Care membership plan covers my portion of Schertz EMS 911 transport services that are not reimbursed by insurance or Medicare.

• I understand that Schertz EMS will bill my insurance or Medicare for all ambulance services and that I may be asked to assist in working with my Insurance or Medicare to complete this process.

• I understand that Medicaid recipients are not eligible for the Schertz EMS membership plan per Texas State Law and I attest I am not a Medicaid recipient upon signing this agreement.

• I understand that if my Insurance or Medicare deems the ambulance transport as not medically necessary or not a covered service, or if I lose insurance coverage at any time during the membership period that I will be responsible for paying a reduced fee for any ambulance transportation received (50% of total charges) and that if I refuse to pay these charges or allow my account to go to collections, I will forfeit the remaining portion of my membership for that calendar year.

• I understand that the Schertz EMS Paramedics that respond to my emergency are not familiar with insurance reimbursement policies and that they are solely concerned for my well-being and in transporting me to the hospital. No statements made or claimed to have been made by Schertz EMS Paramedics will alter my responsibilities under this membership agreement.

• I understand that only 911 transports done by Schertz EMS or Schertz EMS mutual aid agencies in the Schertz EMS response jurisdiction are covered by this membership plan.

• I understand that the Schertz EMS Passport to Care plan is only available to legal residents of Schertz EMS’s primary response jurisdiction which includes the cities of Schertz, Live Oak, Universal City, Selma, Garden Ridge, Cibolo, Santa Clara and Marion as well as only the portions of unincorporated Guadalupe County and Comal County that Schertz EMS serves as primary 911 ambulance transport.

• I understand that my Passport to Care membership is non-transferable and non-refundable.

• I understand that my Passport to Care membership is valid from January 1 through December 31  and becomes active no earlier than January 1  or immediately upon receipt of my application and payment in full after January 1.

• I understand I will be issued a “Passport to Care” Membership Card but that it is not necessary to have that card to take advantage of the plan. The plan will be administered in the Schertz EMS billing office after the transport is completed.

Assignment of Benefits

• I accept Schertz EMS Passport to Care membership and in consideration of the membership fee, I hereby; assign all ambulance benefits that I, or any covered family member, may otherwise be entitled to receive from any insurance or other third-party payer for services provided under my Passport to Care membership. Schertz EMS will accept this assignment as payment in full for 911 ambulance transportation, if insurance or other third-party payers approve payment for the transport.

• I understand that Schertz EMS will file my insurance claim for each covered person and is entitled to receive payment from all insurance or other third-party payers up to the amount of Schertz EMS’s usual charges. If no insurance or other third-party payer benefits are available or the services are denied by the insurance company or other third-party payer, I understand that I will remain responsible for payment of 60% of Schertz EMS’s usual and customary charges for this transport. I agree that any insurance or other third-party payment that I receive related to Schertz EMS’s services provided under my Passport to Care membership shall immediately be forwarded to Schertz EMS.

• I understand that I am financially responsible for the services provided to me by Schertz EMS, regardless of insurance coverage.

Lifetime Signature Authorization

• I authorize and direct any holder of medical information or documentation about me to release to the Centers for Medicare and Medicaid Services and its carriers and agents, as well as to Schertz EMS and its billing agents and any other payers or insurers, any information or documentation needed to determine these benefits or benefits payable for any services provided to me by Schertz EMS, now, in the past, or in the future. I agree to immediately remit to Schertz EMS any payments that I receive directly from any source for the services provided to me and I assign all rights to such payments to Schertz EMS.

• Each member of the household 18 and older (or their authorized agent) must agree to the above terms and sign and date this application showing that he/she had read, understands and agrees to the terms and conditions of the Schertz EMS Passport to Care Plan.