Membership Agreement

This is not an application for an insurance policy. Please read the following then follow the link below to download and print the membership application. Once you have completed the application, return it along with your $59 membership fee by December 31, 2007.

		I understand that the $59 membership fee for REMSA's Silver Saver covers my portion of REMSA's paramedic ambulance services that are medically necessary, and that are applied to co-insurance or deductibles by insurance or Medicare. "Medically necessary" is defined as a specific need for ambulance transportation to or from a health care facility (such as a 9-1-1 emergency call, non-emergency request, or an interfacility transfer) within REMSA's primary service area, where use of other forms of transportation, such as private car or taxi, would be medically inappropriate. I understand that REMSA can require physician certification of medical necessity. I also understand that if abuse of the service is found to exist, my membership may be terminated.
		I understand that my Silver Saver membership covers those persons who are permanently reside in my household and who are included on this application. A "household" is defined as all persons who permanently reside at the "Head of Household's" physical address or in a nursing home.
		I understand that Silver Saver membership is available only to legal residents of REMSA's primary service area, which includes all of Washoe County, Nevada, excluding Gerlach and the North Lake Tahoe Fire Protection District.
		I understand that Silver Saver membership does not cover the service of Care Flight, the emergency medical helicopter service operated by REMSA, or Med-Express Transport.
		I understand that Silver Saver is not an insurance policy, nor is it meant to be a substitute for health insurance. I agree that if I have no insurance or other health coverage, or if my insurance company or other health benefits payer denies payment to REMSA because it determines that my ambulance services were not payable, I will be responsible for the payment of the fees for those services. I agree to pay the fees less a 20 percent discount granted by REMSA because I am a Silver Saver member.
		I understand that this membership plan does not cover the service given by other providers, including other 9-1-1 providers who provide back-up.
		Medicaid patients receive full coverage for services. Therefore, there is no reason for Medicaid patients to become Silver Saver members.
		I understand that the program limits the number of transports per household membership to 10 per year.
		I understand that my membership is non-transferable and non-refundable.
		I understand that the effective date for my membership is the date that REMSA receives my completed and signed Membership Application and fee, and is effective through December 31, of the current application year.
		ASSIGNMENT OF BENEFITS: I understand that my Silver Saver membership is not an insurance plan and that REMSA will bill and receive payments from my insurer or third party (such as Medicare, Blue Cross, etc.). I hereby authorize all benefits to be made directly payable to REMSA. If I have Medicare, I request that payment or authorized Medicare benefits be made on my behalf to REMSA for any ambulance service provided to me by REMSA. If I receive payment from Medicare or my insurance company, I will immediately forward that payment to REMSA. If I do not, I understand that my membership may be terminated and I will be billed full charges for REMSA services. I acknowledge that I am responsible for payment of ambulance services.
		LIFETIME SIGNATURE AUTHORIZATION: To facilitate processing, I authorize the release to REMSA, the Centers for Medicare and Medicaid Services, or other insurer of any medical information or documentation held by anyone necessary to process a claim now or in the future, and further assign and authorize such payments to REMSA. I permit a copy of this authorization to be used in place of the original.

REMSA is compliant with HIPAA regulations. A copy of our Notice of Privacy Practices is available upon request or by clicking here.

Already a member?

Your 2007 renewal application will be mailed to you in a few weeks. If you have not received your renewal materials by December 1, 2007, call (775) 858-5757 or follow the instructions below to download the current application.

Each household member over the age of 18 must agree to the above terms.

Please follow the link below, fill in and print out the Membership Application. Each member must sign and date the application showing that you have read, understand and agree to the Silver Saver terms. Send the completed and signed application along with your payment to:

REMSA Silver Saver

450 Edison Way

Reno, NV 89502

450 Edison Way Reno, Nevada 89502 (775)858-5700 Fax (775)858-5720