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Ambulance Subscription Plan

  1. List all family members living at your residence who will be covered by the plan. Please note: the number of family members listed must be consistent with the plan/level of coverage you have selected.

  2. Upload a current roster or list of employees who will be covered by the plan. Please note: the number of employees listed must be consistent with the plan/level of coverage you have selected.

  3. Only complete if you have selected a business plan.

  4. Would you like to receive email updates about the Ambulance Subscription Plan?*

  5. How did you hear about the Ambulance Subscription Plan?*

  6. Authorization*

    By clicking the “I Agree” button below, I request that payment of authorized Medicare benefits or other insurance benefits be made on my behalf to Caroline County EMS (“CCEMS”) or its billing agent, Medical Claim Aid (“MCA”) for any ambulance and emergency medical services provided to me. I authorize and direct any holder of medical information or documentation about me to release to the Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration) and its carriers and agents, as well as to CCEMS and MCA, any information or documentation needed to determine these benefits or benefits payable for any service provided to me by CCEMS, or related services provided by any other organization performing services in concert with CCEMS, now or in the future. I agree to immediately remit to CCEMS or MCA any payments that I receive directly from any insurer for services provided to me. I understand that failure to remit payment will result in bills going to a third party collection agency. I understand that I will be provided with a copy of CCEMS’s Notice of Privacy Practices at the time of service. I further certify and affirm that I am empowered to authorize the proceeding conditions for any individual covered by the plan I have purchased and that those covered individuals agree to be bound by the terms and conditions listed herein. A copy, including an electronic copy, of this form is as valid as the original.

  7. Leave This Blank:

  8. This field is not part of the form submission.