Terms of Agreement

FireMed is not insurance. It is in addition to any medical benefits members may have. The City of Dallas Ambulance Service will bill insurance or other coverage that members may have for ambulance services. The City of Dallas Ambulance Service is entitled to all benefits paid for ambulance services provided.

Members agree to provide, when requested, any or all information concerning insurance policies, plans, third party recovery, or other benefit programs. Persons covered under the membership will cooperate and assist as necessary in any effort to bill and collect such ambulance reimbursements, including the completion of documents or claim forms.

FireMed membership includes the “Primary member” and all persons who are living together with the Primary Member, as a family unit, in the same single-family occupancy, non-commercial residence within the Dallas Ambulance service area. “Family unit” means persons related by blood, marriage or domestic partnership, as defined in ORS 106.301, and includes household members living in substitute care (e.g., a nursing home) in the service area. The Primary Member must provide satisfactory proof of residence for all persons in the family unit living in the household, other than the Primary Member’s spouse, domestic partner, or minor children of the Primary Member or the Primary Member’s spouse or domestic partner. Evidence of residence may include, but is not limited to, a driver license or DMV identification card, or mail addressed to the resident. Anyone who joins the Primary member’s household after the membership goes into effect can be included under the membership from the date the Primary Member notifies FireMed of the addition, and provides proof of residency, as required. Only those persons who meet the membership eligibility requirements AND are listed in the membership record at the time of service are eligible for benefits.

Coverage includes transport to the nearest appropriate hospital. Physician ordered transfers from one hospital to another that require basic or advanced life support care from an EMT are also covered. Prior arrangement will allow the patient to be transported to the member’s household or a nursing home, if physician and insurance carrier or health maintenance organization representative (if patient has health insurance coverage) authorize the transport. The patient must also:

• require medical care
• require stretcher services
• have proof that they are not able to travel by any other means because of their medical condition.

Advanced Life Support and Basic Life Support are covered by this plan.

All Billing, if any, will be presented to the patient's insurance carrier. All eligible charges not covered by insurance will be waived. Any FireMed member who receives direct payment for ambulance service from his insurance company must forward the payment to the City of Dallas Ambulance Service. An invoice of ambulance charges will be sent to the member.

By not forwarding any or all payments received, the member will be responsible for the entire bill.

Coverage commences upon acceptance of the application by the City of Dallas Ambulance Service and continues to November l of the following year. Payment in full must accompany the application.

The following transports are not covered by this plan:

• Non-emergency transfers to or from doctor's office or clinics.
• Any transfers that do not require Emergency Medical Technicians to provide medical care for the patient or when the patient can be transported by a non-medical transport agency, i.e. wheelchair van, taxi, or private vehicle.
• The nearest appropriate hospital is bypassed due to physician or patient preference; i.e. a Salem hospital is bypassed for a Portland hospital when the Salem hospital can provide for the patient's medical needs.
• Any services that do not require the Emergency Medical Technician to provide medical care for the patient or when request for a specific task has been made; i.e. placing the patient back in bed or a wheelchair, or placing the patient in a private vehicle.

Member will be responsible for the entire payment for services provided which are not covered by this plan.

Cancellation of membership may occur if members repeatedly request ambulance transports that are not covered by the FireMed plan. Members may forfeit their membership payment, and their membership in the FireMed program will be terminated. Members will receive three warnings prior to cancellation. Decisions regarding abuse of service and cancellation of membership will be made by the City of Dallas Fire Chief. The Fire Chief’s decision may be appealed to the City Manager of the City of Dallas.

Reciprocal Billing Agreement

I authorize Dallas FireMed to release all information required for billing purposes to any ambulance provider that has an authorized reciprocal billing agreement with Dallas FireMed.

I further authorize any such ambulance provider from whom we have received service to bill their charges directly to my health insurance carrier(s).

A false statement made in connection with an application for membership shall be punishable as an unsworn falsification under ORS 162.085.