Essex Rescue
 
 
 
 

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Essex Rescue Subscription Agreement
(January 1, 2017 to December 31, 2017)

The subscription plan offered by Essex Rescue is a unique plan designed to help you and the members of your immediate household control your health care costs and at the same time, support the efforts of our volunteers. Your health insurance will be billed for the use of our ambulance for medically necessary services. If you are a participant in our subscriber plan, the co-pay or deductible amount unpaid by your health insurance will be waived. Your insurance company will be billed for our services and we will accept the amount paid by your insurance company as payment in full. Contact Colleen Nesto at (802) 878-4859 x4 for more information.

Subscription Letter

Subscription Brochure

Subscriber Information
       
Name:
Date of Birth:
Address:
City, State, Zip:
Phone:
E-mail:
 
Please list name and age of all others living in your household
 
  Name Date of Birth (mm/dd/yyyy)
   
   
   
   
   
   
   
   
 
Subscription Plan
 
Subscription Amount $
$300+ Platinum Subscriber
$200 Gold Subscriber
$100 Silver Subscriber
$50 Subscriber (minimum)
 
I hereby apply for an Essex Rescue Subscription covering all people living within my house listed on this agreement. I understand that the $50 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 are covered by Essex Rescue. The subscription will begin on January 1, 2017 and end on December 31, 2017. This subscription is terminated if the subscriber moves outside Essex Rescue's primary service area. I understand that if any member of my household uses services of Essex Rescue, a bill will be sent to my insurance company and that I will not be responsible for a co-payment or deductible. Any payment I receive directly from my insurance company must be forwarded to Essex Rescue. This subscription is non-refundable and non-transferable. I authorize payment of medical benefits to Essex Rescue. Any amount paid in addition to the $50 subscription 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.
 
I have read and agree to terms and conditions stated above
 

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Essex Rescue, Inc.
1 Educational Drive
Essex Jct., VT 05452
Emergency Dial 911
Non-Emergency: 802-878-4859
Station Fax: 802-878-1246
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