Annual Membership Terms
The following are terms of the Golder Ranch EMS Membership plan (The Plan):
The Plan is available to all residents of Golder Ranch Fire District (The District) and the family members who live in the resident’s household (provided that they are enrolled in the plan at the time of application) and to individuals with a regular place of work within the boundaries of the District. The Plan covers 911 and interfacility MEDICALLY necessary transports. The Plan covers theportion of patient responsibility not covered by insurance (i.e. deductibles or co-pays). Plan members agree to assist The District in collecting payments from insurance providers, including by not limited to promptly providing necessary information and signatures for submission of claims to insurance providers and taking other steps necessary or reasonably required to facilitate payment to The District. If the Plan member receives a payment for the ambulance transport directly from their insurance provider, the member will immediately forward such payment to The District. Failure to remit payment to The District within five days of receipt will result in the Member being responsible for the full cost of the transport pursuant to The District’s fees schedule in effect at the time of the Member’s ambulance transport.
The Plan membership will be effective for twelve full months upon receipt of full payment together with a signed membership agreement. The Membership fee is non-refundable and non-transferable. The undersigned member request that payment of authorized benefits be made on my behalf to:
Golder Ranch Fire District | 3885 E. Golder Ranch Dr. | Tucson, AZ 85739
direct 520-825-5902 | fax 520-825-5985
The undersigned member authorizes any medical information or documentation about the member to release any information or documentation needed to determine these benefits or benefits payable for related services provided by The District now or in the future.
NOTICE: In the event your check is dishonored or returned for any reason, you authorize us to electronically (or by paper draft) re-present the check on your bank account for the collection of the amount of the check plus any applicable fees as permitted by law. THE USE OF A CHECK FOR PAYMENT IS YOUR ACCEPTANCE OF THIS AGREEMENT.
By submitting this form, I agree to the terms and conditions listed.
Golder Ranch EMS Membership is pre-paid service program offered by Golder Ranch Fire District. At no time will you be denied emergency medical services or transport based on insurance status or ability to pay.