VBEMS

Benefits	Includes non-emergency transfers by wheelchair equipped van, and also non-emergency ambulance transports: Transportation Plus! Services Ambulance Service	Includes non-emergency transfers by wheelchair equipped van only: Transportaion Plus! Services
Eligible Areas	Exclusive for residents of these townships: Almena Arlington Antwerp Decatur Hamilton Lawrence Paw Paw Porter Waverly	Any residents of Van Buren County including townships of: Bloomingdale Bangor Columbia Covert Geneva Hartford Keeler Pine Grove South Haven
Fees	$40 per household with insurance $80 per household without insurance	$80 per household

What exactly is a household.

I understand and I am responsible for payment of all ambulance and transport van services. The annual $40 membership for Full Membership limits my out-of-pocket cost for medically necessary ground ambulance transportation covered by insurance. ($80 membership fee for those without insurance coverage) I understand that the Limited Membership covers non-emergency transfer by wheelchair equipped van. I understand that air ambulance is not covered by this membership. I understand that I must use the services of VBEMS in order to be eligible for membership benefits.

Membership Period: I understand that my membership is effective upon receipt of full payment and signed membership agreement and coverage is through June 30th of the year following enrollment.

Remittance: I understand that VBEMS Membership Program is not an insurance program and that VBEMS will bill my insurer or third party agency (Medicare, Blue Cross, etc), including any supplemental or complimentary insurance. If the insurance company sends me a check for services provided by VBEMS, I agree to promptly forward that payment, in full, to VBEMS. I hereby authorize payment directly to VBEMS, Inc. for ambulance services otherwise payable to me. I authorize any holder of medical or other information about me needed to determine these benefits now or in the future, to release it to the Health Care Finance Administration (CHFA), its agents, other insurance carriers, or VBEMS, Inc.

Medically Necessary: I understand that VBEMS ambulance membership services are limited to medically necessary services, defined as the specific need for ambulance services transportation to or from the hospital, or nursing facility, within Van Buren County and surrounding counties, where use of alternative forms of transportation (wheel chair van, private vehicle, public transportation, taxi) would be medically inappropriate given the nature of my medical condition. VBEMS requires Physician Authorization of Medical Necessity. I understand VBEMS, Inc. can terminate this membership if there is evidence of abuse of this program. This program does not cover ambulance transport to or from a physician’s office by ambulance.

Service Area: I understand that VBEMS, Inc. may charge me additional fees if long distance and/or non-emergency ambulance services are required outside the VBEMS, Inc. service area. I also understand that if local service is requested that is not medically necessary and/or is other that to or from a hospital or nursing facility, VBEMS, Inc. may charge additional fees.

Coverage: VBEMS, Inc. membership covers those residing in your household. A household is defined as husband and wife, or single parent, their children under age of 21 living at the same address, or a single individual household.

Transportation Plus Services: Transportation Plus offers transportation by a wheelchair-equipped van for persons whose mobility is restricted and who need assistance to and from medical destinations. I understand that Medicare, Medicaid, and many other insurance carriers do not cover van services. I understand that I am financially responsible for all Transportation Plus services. Transportation Plus service will be offered to members at a 20% discount off our regular rates.