Western Lane Ambulance District
410 Ninth Street/ P.O. Box 2690/ Florence, OR 97439
Coverage begins two business days after acceptance of a properly completed application form with payment and extends to July 31 of the following year.
I hereby apply for membership in Western Lane Ambulance LifeMed program for myself and my household members for the LifeMed fiscal year from June 1 –July 31. I understand that the membership fee of $65.00 provides only medically necessary pre-hospital care and transportation within the LifeMed Reciprocal areas. I request that payment of authorized Medicare, Medicaid or any other insurance benefits be made on my behalf to the ambulance supplier for any service provided to us past, present or future. I agree to immediately remit my ambulance supplier any payment that I receive directly from insurance or any source whatsoever of the services provided to me or my family and I assign all rights to such payments to my ambulance supplier. A copy of this form is as valid as the original.
- I understand that medical transportation is based on medical necessity, not on membership status and that the patient will be transported to the closest medically appropriate facility.
- I understand that my membership covers only ambulance transports in our reciprocal area which are medically necessary. Please refer to the reciprocal agency map.
- I understand that LifeMed is NOT insurance but after the primary and secondary insurances are billed, and if any co-pays or deductibles, remain they will be written off.
- I further authorize the release of medical information for the purpose of ambulance insurance billing only.
- I understand that violations of the terms of this agreement may result in immediate This membership is non-refundable. Although we offer year round enrollment there is no pro-ration in premium and the membership will expire on the 31st of July.
DEFINITION OF HOUSEHOLD:
Membership includes all persons who are permanent residents of the same single-family occupancy, non-commercial residence, living within LifeMed’s ambulance service areas, living together as part of a family unit, including domestic partners, but not to include roomers or boarders. Membership benefits include household members living in substitute care (Exp. Nursing homes). Others not included in this definition are required to obtain their own separate memberships.
Disclaimer: LifeMed membership is not intended to solicit Medicaid enrolled patients, and such membership constitutes a voluntary contribution only. Persons who receive welfare, Medicaid, Department of Medical Assistance Programs, or Oregon Health Plan medical benefits need not be members in order to have full coverage for services covered under these programs. Violations of the terms of agreement may result in membership revocation, forfeiture of benefits associated with membership and an obligation to pay all balances in full.
DEFINITION OF Medically Necessary: Medically Necessity is satisfied when the “lack of transport” could place the patient’s health in serious jeopardy; could cause impairment of bodily functions; or another mode of transportation could endanger the health of the patient. LifeMed does not cover non-emergent transfers from the hospital to home or a lower level of care.