Your Name__________________________________SSN_________________
Spouse_____________________________________SSN_________________
Your Birth Date____________________Spouse Birth Date________________
Your Medicare#____________________Spouse Medicare_________________
Other Insurance___________________________________________________
Mailing Address________________________________City________________
Zip_______________Phone#______________________
Children_________________________________________________________
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I acknowledge that I am responsible for payment of service. Membership coverage is limited to medically necessary ambulance transports. I request that payment of autherized Insurance benifits be made on my behalf to Southeast Emergency Medical Service, Inc for any ambulance service provided to me.
I autherize any holder of medical information or documentation about me to release it to the Health Care Financing Administration and its agents, as well to Southeast Emergency Medical Service, Inc, any information needed to determine these benefits payable for related services provided to me by "SEEMS" now or in the futuer.
Recipients of Medicaid should not purchase a membership, as beneficiaries are entitled to Medicaly Necessary covered ambulance service at no direct cost. However, Donations are accepted to help cover the cost of ambulance service not covered by Medicaid.
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Signature___________________________________
Signature___________________________________
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