Fillable Gvfd Ambulance Subscription Program 2020

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Gvfd Ambulance Subscription Program 2020

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_______________________________________________________________________________________________
GVFD Ambulance Subscription Program 2020
Page 1 of 4
City of Gustavus
PO Box 1
Gustavus, Alaska 99826
Phone: (907) 697-2451
GUSTAVUS VOLUNTEER FIRE DEPARTMENT (GVFD) AMBULANCE SUBSCRIPTION PROGRAM
At the April 14, 2014 General Meeting, the City Council adopted an Ordinance (Title 6.02), authorizing
the GVFD to collect fees for ambulance calls, and a fee schedule was implemented that year (Resolution
CY14-21) and updated in 2019 (Resolution CY19-18).
The City of Gustavus and GVFD offers a program for ambulance subscription. As an Ambulance
Subscriber, we will only bill insurance providers for the rates listed on page 2. Payment from a
subscriber’s insurance carrier will satisfy your obligation to us for our service rates. This does not
include “additional fees” as applicable. Subscribers with no insurance coverage will have the same
benefits as subscribers with insurance coverage. Non-Subscribers are responsible for payment in full
for services, regardless of the amount covered by their insurance carrier. Subscribers shall forward any
payments received directly from their insurance carrier to the City of Gustavus immediately upon receipt.
Coverage Offered:
Individual Subscriber $10.00 per person annually
Household Subscriber $25.00 per household annually. For the ambulance subscription program
purpose, a household consists of the head of household, spouse/partner,
unmarried dependent children under the age of 25, and any other legal
dependent all which live in the same household.
The names of all persons covered must be listed on subscription form. The subscription will become
effective on the date the enrollment form and payment are received at City Hall and will be valid for
that calendar year.
The GVFD is a department of the City of Gustavus, a non-profit municipal government. As such, any
surplus we may generate each year is used to enhance the operations of the GVFD and prepare for
future growth in the community. The City of Gustavus and the GVFD strive to make this program
available to everyone in our response area. Additional contributions are always welcome, and greatly
appreciated. We thank you in advance for your support, and we continue to strive to offer the highest
quality emergency medical services possible.
Terms of Service:
1. The GVFD subscription service is completely voluntary.
2. GVFD ambulance subscription is not available to businesses, nor does it cover caregivers or
employees of subscribing members, part-time guests, or temporary visitors.
3. The subscription has open enrollment, and subscriptions are valid yearly from January 1
st
to
December 31
st
.
4. If an individual or household moves out of Gustavus, no refund, pro-ration or adjustments will
be made. The subscription is non-transferable.
5. There will not be any reminders for renewal mailed to subscribers. The next yearly forms will be
available at City Hall starting in December of each year.
6. The basic charges as defined in “Rates”, and listed below, are waived for subscribers; however,
charges for supplies and escort fees are not waived.
_______________________________________________________________________________________________
GVFD Ambulance Subscription Program 2020
Page 2 of 4
7. The subscription will not cover “additional fees” as listed below.
8. Subscribing members will be responsible for payment of services previous to the subscription
activation.
9. Authorization for the City of Gustavus to obtain entitled benefits from insurance carriers and
Medicare will be required.
a. Insurance carriers will be billed for services provided to subscribers, however no out of
pocket costs will be billed to subscribers.
Rates:
1.
Acuity Level I
Basic Life Support (BLSI)
$500/call plus mileage
2.
Acuity Level II
Basic Life Support Emergency (BLSIIE)
$600/call plus mileage
3.
Acuity Level III
Advanced Life Support (ALSIII)
$700/call plus mileage
4.
Acuity Level IV
Advanced Life Support Emergency (ALSIVE)
$800/call plus mileage
5.
Acuity V
Critical Care (AVCC)
$1000/call plus mileage
6.
Treat and No Transport
$500/call
Transportation fee is set at $11/mile.
Additional Fees:
1. Additional fee of $3.00/minute in the event Medevac transportation is delayed beyond one (1)
hour, by the patient, the discharging facility, the receiving facility or by other transportation
facilities.
2. If a medevac escort is needed, it shall be billed accordingly to recover the entire cost of the
Emergency Medical Technician (EMT)’s travel for patients transported by air, road, or water
to patient care facilities outside of Gustavus.
3. Charges for transportation for private carrier will be billed directly to the patient by the
carrier.
To sign up for the subscription program, please fill out and bring the attached form to City Hall. We will
also need HIPAA forms signed (available at City Hall), and a copy of the insurance policyholder’s driver’s
license, as well as a copy of the insurance card(s). These forms are available on the City of Gustavus
website at: https://cms.gustavus-ak.gov/administration/page/ambulance-subscription-program
Further questions may be directed to GVFD Fire Chief, Travis Miller at 697-2707.
_______________________________________________________________________________________________
GVFD Ambulance Subscription Program 2020
Page 3 of 4
City of Gustavus, Alaska
Gustavus Volunteer Fire Department Emergency Medical Services
Ambulance Subscription Program
PO Box 1
Gustavus, Alaska 99826
THIS IS NOT AN INSURANCE POLICY
I request that payment of authorized insurance benefits be made on my behalf to the City of
Gustavus for any services provided to me by the Gustavus Volunteer Fire Department now or
in the future. I agree to immediately remit to the City of Gustavus any payments that I receive
directly from insurance or any source whatsoever for the services provided to me, and I assign
all rights to such payments to the City of Gustavus. I authorize the GVFD or contracted billing
service to appeal payment denials or other adverse decisions on my behalf without further
authorization. I authorize and direct any holder of medical information or documentation
about me to release such information to Gustavus Volunteer Fire Department and its billing
agents, and/or the Centers for Medicare and Medicaid Services and its carriers and agents,
and/or any other payers or insurers as may be necessary to determine these and other
benefits payable for any services provided to me by the Gustavus Volunteer Fire Department,
now or in the future. A copy of this form is as valid as an original.
Subscribers to the Ambulance Subscription Program agree to notify City Hall within 7 business
days of any and all changes in insurance coverage, including but not limited to termination or
activation of coverage or change in insurance carriers.
I hereby apply for membership with the Gustavus Volunteer Fire Department Ambulance
subscription program. I understand that the enclosed fee will cover me, my spouse or partner,
unmarried dependent children under the age of 25 years of age, and any other legal
dependent of me and my spouse/partner who may live at this address.
I understand that through my membership, the Gustavus Volunteer Fire Department will
provide emergency ambulance service within Gustavus. I also understand and give my
permission for the Gustavus Volunteer Fire Department to bill my insurance carrier(s). This
membership will cover the portion not reimbursed by my medical coverage for services
rendered by the Gustavus Volunteer Fire Department. I understand that the Gustavus
Volunteer Fire Department provides medically necessary ambulance transportation and that
violations of the terms of this agreement may result in immediate cancellation of my
membership or other penalty. I also understand that
this membership is nonrefundable and
nontransferable.
Signature of Subscriber/Head of Household Date
click to sign
signature
click to edit
_______________________________________________________________________________________________
GVFD Ambulance Subscription Program 2020
Page 4 of 4
GVFD AMBULANCE SUBSCRIPTION PROGRAM ENROLLMENT FORM - CALENDAR YEAR 2020
Head of Household:
Printed Last Name Printed First Name
DOB
Street/Mailing address
Insurance Carrier ID# Group#
□HIPAA form signed
Eligible residents in household:
1.
First and Last name DOB
Insurance Carrier ID# Group#
□HIPAA form signed
2.
First and Last name DOB
Insurance Carrier ID# Group#
□HIPAA form signed
3.
First and Last name DOB
Insurance Carrier ID# Group#
□HIPAA form signed
4.
First and Last name DOB
Insurance Carrier ID# Group#
□HIPAA form signed
Method of Payment:
*Attach a separate sheet if necessary
The full amount of $10/individual or $25/household is due and payable at the time of enrollment.
Enclosed check #______ made payable to: City of Gustavus
Visa/MC/Amex/Discover
Card # Exp. date
Billing address and Zip Code for Card
Name as it appears on card Authorized signature of cardholder
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Completed 12 July 2020

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