LifeMed Agreement

Western Lane Ambulance District
410 Ninth Street /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 Ambulance ~ 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.