ROGUE RIVER FIREMED AGREEMENT

I hereby apply to Rogue River FIREMED for membership for myself and listed eligible family members*. I understand the membership fee provides MEDICALLY NECESSARY** pre-hospital care and ambulance transportation. Coverage is immediate from acceptance of application by Rogue River FIREMED, and extends through November 30 of the following year. I understand that Rogue River FIREMED is not insurance, but provides prepaid coverage in excess of any health insurance of medical benefits I may have. I authorize Rogue River FIREMED to bill direcely for ambulance service to any such insurance. I agree to assign to Rogue River FIREMED any claim I may have for medical insurance for the purpose of ambulance insurance billing only, including reciprocal FIREMED agencies. Should I or a family member receive payment from insurance or any other medical benefit provider for ambulance service provided by Rogue River FIREMED, I will immediately forward such payment directly to Rogue River FIREMED. Failure to do so may be grounds for cancellation of Rogue River FIREMED agreement. This membership is non-refundable and non-transferable. Rogue River FIREMED membership is not solicited from persons who receive medical welfare benefits. Such membership constitute a voluntary contribution only.

I authorize a copy of this Agreement to be used in lieu of the original on file by Rogue River FIREMED. I authorize payment of insurance benefits for ambulance service for myself and family members directly to Rogue River FIREMED ambulance service according to the Rogue River FIREMED agreement and as itemized on submitted claims.

A Rogue River FIREMED membership covers the immediate family. The immediate family including member, spouse, unmarried children under age 21, or persons listed as legal dependants for income purposes living within the household are covered. OTHERS NOT INCLUDED IN THIS DEFINITION ARE REQUIRED TO OBTAIN SEPARATE MEMBERSHIPS. A spouse or dependant living in a nursing home or licensed residential care facility is covered if the care facility is within Rogue River FIREMED service area boundaries. New dependants during the term of a Rogue River FIREMED membership are automatically covered.

A Rogue River FIREMED membership provides emergency pre-hospital medical care and ambulance transportation, and specified MEDICALLY NECESSARY ** PHYSICIAN AUTHORIZED non-emergency ambulance transportation. All emergency service must originate or terminate within the boundaries of Rogue River FIREMED Ambulance Service Areas. Emergency transportation will be to the nearest medically approved hospital as determined by Medical Control physicians.

Non-emergency ambulance transportation to hospitals, 24-hour emergency medical receiving facilities, nursing homes, adult foster care homes, and private residence is covered when medically necessary and with prior authorization by a physician. Such transportation is limited to Rogue River FIREMED service area, except that medically necessary and physician authorized transfers to Medford or Grants Pass area hospitals ARE covered. Transfers beyond these areas will be filled at normal rates.

Specifically NOT COVERED is non-medically necessary transportation where means other than ambulance should be used, including private vehicle, taxi, or wheelchair and stretcher van services. Examples of such uncovered services may include transportation to and from doctors offices of clinics, transportation from nursing homes for treatment normally provided in nursing home, or transport back home from a medical facility when patient condition does not warrant an ambulance.

1) ANY PATIENT WHO NEEDS OXYGEN, IV FLUIDS, CARDIAC MONITORING, AND/OR CONTINUOUS MEDICAL OBSERVATION AND EVALUATION. 2) ANY PATIENT WHO PHYSICALLY CAN'T BE TRANSPORTED BY PRIVATE VEHICLE WHEN ALTERNATIVE TRANSPORTATION (i.e., taxi-cab, private vehicle) CAN'T BE SECURED. (PHYSICIAN AUTHORIZED).

Member benefits are extended to areas outside the Rogue River FIREMED service area, but within the State of Oregon. These benefit are limited to the terms of agreement in effect by each FIREMED participating agency at the time benefits are used. Members who receive ambulance service from any other FIREMED participating agency are eligible for benefits offered by that agency provided that: 1) a copy of the ambulance bill is submitted to Rogue River FIREMED within 30 days of receipt of bill, 2) the member hereby agrees to the terms of the participating agency's agreement. A current list of FIREMED participating agencies is on file in the FIREMED business office.