PLEASE PRINT (Fill out completely) Date ____________________
LAST NAME ____________________________________________________Telephone _________________________
Street Address ____________________________________________________________________Apt. # ___________
City ___________________________________________________________State _____________Zip _____________
Mailing Address (if different than above)_________________________________________________________________
City ___________________________________________________________State _____________Zip _____________
Membership (check one): New M Renewal M
Please answer the following insurance questions. CHECK APPROPRIATE BOXES: YES NO
Does anyone on your FireMed membership have Medicare? M M
Does anyone on your FireMed membership have medical insurance in addition to, or in place of Medicare? M M
Does anyone on your FireMed membership have Medi-Cal? M M
Where did you hear about FireMed? In the mail M Newspaper M Radio M Other ______________
As discussed in the terms of agreement, FireMed will bill your insurance and accept whatever it pays
as payment-in-full. You will owe nothing.
Please fill this form out completely, sign the signature form below (all appropriate family members),
and return this form along with the fee by October 31st.
Household Members First Middle Relationship to Date of Birth
Last Name (if different from Head of Household) Name Initial Head of Household Mo. Day Yr.
Head of Household _________________________________________________________________________________
Spouse or Dependent _______________________________________________________________________________
Dependent _______________________________________________________________________________________
Dependent _______________________________________________________________________________________
Dependent _______________________________________________________________________________________
Dependent _______________________________________________________________________________________
Dependent _______________________________________________________________________________________
APPLICATION FOR MEMBERSHIP
Your #1 Lifesaving Team
FireMed is the Lifesaving Emergency Ambulance Membership Program
of the Dinuba, Kingsburg, Sanger and Selma Fire Departments.
ENROLLMENT LIMITED TO SEPTEMBER AND OCTOBER
$65
420 E. Tulare St.
Dinuba, CA 93618
559-591-5931
Male/
Female
FIREMED AGREEMENT
(Please read information carefully before signing below.)
I hereby apply for membership in FireMed for myself and eligible* family members who live at my address. I understand the enclosed fee
provides emergency ambulance care and transportation within the Tri-County FireMed service areas, and non-emergency ambulance
service as noted below. If an additional transport is required between health facilities, another ambulance company may be involved and
this additional transport may not be covered by FireMed. Coverage begins upon acceptance of the application and extends to October 31
of the following year. Non-emergency ambulance service to hospitals and 24 hour emergency medical receiving facilities, are covered
when medically necessary by your insurance with prior written authorization by a physician. I understand that FireMed is not
insur-
ance but will provide ambulance service through the Tri-County FireMed and will bill whatever insurance or medical benefits I may have and
is entitled to primary and secondary insurance payment. FireMed is in excess of any insurance or medical benefits which I may have. I
further authorize the release of medical information for the purpose of ambulance insurance billing only. Should I or a family mem-
ber receive payment from insurance or other medical benefits provider for ambulance service rendered by the Tri-County FireMed, I will
immediately forward such payment to the appr opriate transporting agency. FireMed membership may be considered for welfare
recipients for services that may not be covered under their plan. I understand that violations of the terms of this agreement may result in
immediate cancellation. This membership is non-refundable and non-transferable.
*DEFINITION OF FAMILY
FireMed membership covers immediate family members living in the same household. The member, spouse, unmarried children under
age 25 and other persons listed as legal dependents for income tax purposes are covered. Others not included in this definition are
required to obtain their own separate membership.
TO THE INSURANCE CARRIER
I authorize a copy of this agreement to be used in lieu of the original on file at the FireMed office. The original may be furnished on
request. I authorize payment of insurance benefits for ambulance service for myself or family members directly to the appropriate trans-
porting agency, according to the FireMed agreement and as itemized on the attached claims. I have paid the co-payment for ambulance
service to be rendered and expect your usual and customary ambulance reimbursement on my behalf to be sent directly to the
appropriate transporting agency.
This form must be signed by all persons in the household covered by this membership 18 years of age and older.
Head of Household ____________________________________________ Spouse_____________________________________________________
(Signature) (Signature)
Dependent __________________________________________________ Dependent _________________________________________________
(Signature) (Signature)
A check, money order or cash must accompany this application. Please make check payable to FireMed.
I have enclosed payment by: ( ) Money Order ( ) Cash ( ) Check
YOUR CANCELLED CHECK OR MONEY ORDER RECEIPT IS PROOF OF MEMBERSHIP
© 2009 All Rights Reserved 832311
