Western Lane Fire and EMS Authority
2625 Highway 101 / Florence, OR 97439

Administrative Office: 2625 Hwy 101 / Florence OR 97439
541-997-9614

LIFEMED AGREEMENT

Coverage begins two (2) business days after acceptance of a properly completed application form with payment and extends through the next June 30th.

We hereby apply for membership in Western Lane fire and EMS Authority ~ LifeMed Membership Program for our home* for the LifeMed fiscal year from July 1 – June 30. We understand that the membership fee of $65.00 provides only medically necessary** pre-hospital care and ground transportation within the LifeMed reciprocal areas. We request that payment of authorized Medicare, Medicaid or any other insurance benefits be made on our home(s)* behalf, to the ambulance supplier for any service provided to us past, present or future. We agree to immediately remit the ambulance supplier any payment that anyone in my home* receives directly from insurance or any source whatsoever of the services provided to or by members of my home*, and we assign all rights to such payments to the ambulance supplier. (A copy of this form is as valid as the original.)

• We 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, as is required by law.
• We understand that the Membership covers only ground ambulance transports in our reciprocal areas, which are medically necessary**. Please refer to the Reciprocal Participating Agencies list & map, for over 80 agencies throughout the state of Oregon.
• We understand that LifeMed is NOT insurance, but after the primary and secondary insurances are billed. If any co-pays or deductibles remain, they will be written off.
• We further authorize the release of medical information for the purpose of ambulance insurance billing for our home*.

*DEFINITION OF HOME:
Membership includes all persons who are permanent residents of the same family home, non-commercial residence, and living together as part of a family unit, living within LifeMed’s ambulance service areas. Roomers or boarders are excluded and required to obtain their own separate memberships. Membership benefits also include household members living in substitute care (ex: nursing homes or care facility). Anyone who joins a home after the membership goes into effect can be included under the membership two (2) business days after notification to us. Those persons who meet the membership definition and are listed on the membership record at the time services are rendered eligible for membership benefits.

**DEFINITION OF MEDICALLY NECESSARY:
Medically Necessary 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 to a lower level of care.

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.

Q. How can I sign up for LifeMed?
A. Open enrollment is year round, but it is an annual program, and therefore extends through June 30th each year. You can enroll right here online or pick up an applications at Western Lane Ambulance District’s Admin office, Peace Harbor Hospital, Peace Health Siuslaw Region Clinics, or call 541-997-9614 and we will mail an application to you.

Q. If I don’t belong to the Membership Program will the ambulance still come if I call 911?
A. Absolutely, we will still provide you and your household with excellent service. The Membership Program only has to do with the billing portion, of how we charge for our service.

Q. Is Western Lane Ambulance LifeMed Program part of the FireMed program?
A. Yes, we work as an independent agency but participate with 80+ reciprocal FireMed Agencies in the State of Oregon. A list of participating agencies has been enclosed in this packet.

Q. Who does the membership cover?
A. (See Agreement) 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 temporary stays or boarders; those which are listed on the membership application. Membership benefits include household members living in substitute care (ex: nursing homes). Others not included in this definition are required to obtain their own separate memberships.

Q. Is it insurance?
A. No, it is a paid subscription to the ambulance membership program.

Q. When does the Western Lane Ambulance LifeMed Membership expire each year?
A. All Western Lane Ambulance “LifeMed Membership’s” extend through June 30th each year; regardless if you sign-up in July or January.

Q. What does Western Lane Ambulance LifeMed Membership pay for?
A. LifeMed covers the co-pay, deductible or limitations on your policy that your insurance doesn’t always cover for medically necessary (See Agreement) pre-hospital care and ground transportation only which . We accept your insurance, Medicare or third party payer as payment in full, even if your insurance doesn’t pay the full cost of the transport. In the event you have no insurance, you are still covered under the LifeMed program.

Q. Does it cover transportation to hospitals in other cities?
A. Federal law requires the patient be taken to the nearest appropriate facility. However, if the Emergency Room or admitting physician deems ambulance transport to a different hospital is in the best interested of the patient – yes, LifeMed covers the co-pay or deductible.

Q. Does Western Lane Ambulance LifeMed Program coverage include out-of-state ambulance services?
A. No, it only covers our local service area and those of the Reciprocal Agencies participating through FireMed throughout Oregon.

Q. Is the $65 membership fee ever refundable or prorated should I move out of the Florence area?
A. No. Once you have paid the membership fee for the current year, no refund is given and no prorate of service is offered at this time.

Q. What type of service does Western Lane Ambulance LifeMed Program not cover?
A. Western Lane Ambulance LifeMed does not cover non-emergency ambulance calls; such as trips from a nursing home to routine dialysis treatments or visits to your doctor, or non-emergency transportation from a medical care facility.

Membership translates into significant savings and is a very smart investment in peace of mind for you and your family.

Your privacy is important to us. Please be assured Western Lane Ambulance District does not
sell, rent, or trade your personal information to others.