I hereby apply for an Essex Rescue and Richmond Rescue subscription covering all people living within my house listed on this agreement. I understand that the subscription fee for the plan selected per household is not prorated and provides unlimited pre-hospital emergency care, when medically necessary, to me and my listed household members within the primary service area covered by Essex Rescue.
I understand that this agreement only applies to emergency medical services provided by Essex Rescue and Richmond Rescue between January 1, 2024 to December 31, 2024.
This subscription is terminated if the subscriber moves outside Essex Rescue's primary service area. I understand that this subscription permits Essex Rescue, Inc., to collect directly from any third-party agency whatever benefits may be available at no charge to me or my household members, and that this subscription is nonrefundable and is nontransferable.
I request payment of authorized Medicare benefits and/or other insurance benefits be made on my behalf to Essex Rescue, Inc., whether in the past, present, or in the future. I authorize any holder of medical information about me or other relevant documentation about me to be released to Centers for Medicare and Medicaid Services and its agents and contractors, any and all appropriate third-party payers, whether in the past, present or in the future. I understand that any insurance payment received directly by the patient from their insurance company for services provided by Essex Rescue must be surrendered to Essex Rescue.
I understand that a completed, signed subscription agreement form with full payment must be received prior to EMS services provided for the terms of this agreement to be valid. Partial year subscriptions will not be prorated to remaining subscription months.
Any amount paid in addition to the selected subscription coverage fee is a donation which is greatly appreciated by Essex Rescue. Gifts and donations to Essex Rescue, a 501 (c)(3) non-profit organization, are tax deductible within the limits of federal and state laws. Essex Rescue does not provide goods or services as whole or partial consideration for any donations or gifts. Please keep the yellow copy of this form for your tax records along with your canceled check or bank statement.
