Membership Application

THIS AGREEMENT IS NOT INSURANCE
I understand that this membership is not an insurance policy or supplement. By becoming a member, my responsibility to pay uninsured portions of my ambulance bill may be greatly reduced. This reduction may be up to half of the total fee for ambulance calls depending on services rendered.

SERVICES AND COVERAGE AREA
I further understand that this covered is for medically necessary trips to the nearest hospital in the EASI service area. Service area includes the entirety of Bradley, Lincoln, Cleveland and Jefferson counties, the England 911 service area, Clarendon, and DeWitt. I understand the coverage area may change from time to time.

WHAT IS MEDICALLY NECESSARY
Medically necessary trips are defined as “the specific need for ambulance transportation and the only way to travel by means of a stretcher to and from a health care facility (hospital or nursing home) when use of alternative forms of transportation, (e.g. wheelchair transport, private car, taxi) would be medically inappropriate, given the patient’s condition.” EASI reserves the right to require physician certification of the medical necessity of non-emergency trips.

NON-EMERGENCY AMBULANCE SERVICE
I understand that ambulance transportation to a physician’s office, clinic or other destination may not be eligible for payments by insurance and I understand that I will be responsible for these ambulance charges if not covered by my insurance. I also understand that for trips to a physician’s office, clinic or other destination not covered by my insurance, I will receive up to a 50% discount from EASI ambulance charges depending on services rendered.

TRIPS OUTSIDE EASI’S SERVICE AREA
I further understand that if emergency or non-emergency necessary ambulance transportation is required outside of any part of EASI’s service area, additional fees will be charged and will be my responsibility.

EASI TO RECEIVE YOUR INSURANCE AMBULANCE BENEFITS
I, the undersigned, hereby authorize payment of the ambulance benefits otherwise payable to me but not to exceed the regular charges for this type of service, now and in the future, directly to EASI, 514 W. 5th Avenue, Pine Bluff, AR 71601.

I hereby authorize EASI to release the records and any other information regarding my ambulance transportation to any insurance company or employer having coverage on me. If I am entitled to benefits, I authorize any holders of medical or other information about me to release to the Social Security Administration or other intermediaries EASI or carriers, any information needed now or in the future. I agree that a copy of this authorization is as effective as the original. I authorize any holder of medical information about me to release to EASI any information or documentation needed to determine these benefits or benefits paid for related service provided to me by EASI now of in the future. I understand that this authorization can be revoked at any time by writing EASI and revoking same. I understand I am financially responsible to EASI for charges not covered by the authorization, and guarantee payment of all charges within 45 days of service. I further agree that if collection action is made necessary, I agree to pay all collection costs including reasonable attorney fees, I hereby release said EASI and employees from any claim whatsoever.

This membership is non-transferable and permits EASI to collect directly from any third party whatever benefits may be available.

RECURRENT PAYMENTS

I authorize EASI to charge my checking/savings account or credit card account for the current amount of the membership (Individual or Family) level I have selected on a yearly basis. I understand I will incur an additional $3 convenience fee by selecting to use a credit or debit card for payment. I accept I will receive an email receipt of this transaction to the email address I have provided and do not hold EASI responsible for receipts that are sent to an incorrect email address or spam folder.

AUTOMATIC RECURRING PAYMENT FAILURE
I understand I will be contacted by phone or email if my recurring payment is declined for any reason. I further understand my membership will be cancelled if I am unable to rectify my account within 10 days of contact due to failed payment and all membership benefits will be revoked.

MEMBERSHIP CHANGES AND CANCELLATION
I understand I have the right to withdraw consent of this Automatic Recurring Payment at any time during my membership year. I accept the responsibility to make changes my EASI Membership prior to my renewal date.

TO CANCEL OR CHANGE YOUR MEMBERSHIP DETAILS:
Contact the EASI Business Office at info@easimedics.com or by phone at 870-536-0734

EASI does not discriminate or deny services based on race, color, or national origin.

For new memberships (not renewals) there is a 10-day waiting period from the time payment is received at EASI’s office until member benefits apply.