By purchasing a membership, you must agree to the following:
I acknowledge my insurance provider and/or I am responsible for payment of ambulance services provided to me by Mercy Hospital El Reno EMS. I acknowledge it is my responsibility to provide Mercy Hospital El Reno EMS with any valid insurance and third-party payer information pertaining to me or anyone living in my household, and failure to do so nullifies this agreement. In addition, I agree to furnish any information requested by my insurance company in order to facilitate payment of ambulance claims for me or anyone living in my household. In consideration for payment of the membership fee, I hereby assign to Mercy Hospital El Reno EMS all ambulance benefits that any covered family member or I may otherwise be entitled to receive from any insurance or third-party payer for services provided under my Mercy Hospital El Reno EMS membership. If no insurance company or other third-party benefits are available, I understand as a subscriber of Mercy Hospital El Reno EMS, I will remain responsible for payment of Mercy Hospital El Reno’s services at a reduced rate of 60 percent of the standard rate. Any insurance or other third-party payment I receive related to Mercy Hospital El Reno EMS services provided under this membership must immediately be delivered to Mercy Hospital El Reno EMS if there is an outstanding balance on my account. Violation of the terms of this agreement will result in termination of this agreement, and the patient or responsible party will be billed for all charges related to services provided.