SAFEGUARDTM Subscription Agreement   

Thousand Islands Emergency Rescue Service Inc. (TIERS) provides emergency ambulance service to the Towns of Orleans and Clayton. (TIERS) administers the SAFEGUARDTM  program for persons who work, live, and frequent the ambulance district. As a subscription member of SAFEGUARDTM , I understand I am responsible to pay for all services provided by (TIERS). My SAFEGUARDTM  membership covers deductible and co-insurance amounts allowed, but not paid, by my insurance. I also understand that (TIERS) will accept assignment of benefits from my insurance company on all claims for medically necessary ground ambulance transportation and I agree to assign all such benefits to (TIERS). In order for TIERS emergency ground ambulance transportation to be covered by SAFEGUARDTM  membership, they must meet the guidelines of medical necessity as defined by the Health Care Financing Administration, Medicare, or my private insurance company. This may require physician certification of medical necessity. My SAFEGUARDTM  membership does not cover services by companies other than (TIERS). My SAFEGUARDTM membership is good throughout the Towns of Clayton and Orleans. To be eligible for the SAFEGUARDTM Membership Program, I must reside, work, or travel regularly within the Towns of Clayton or Orleans.

 

I understand by becoming a SAFEGUARDTM member in no way obligates (TIERS) to provide ambulance service to me. Rather, my membership obligates (TIERS) to look first to my insurance company or Medicare for payment of my bill in the event that I use the ambulance. TIERS SAFEGUARDTM Membership Program is NOT an insurance program. TIERS will receive payment directly.

 

Thousand Islands Emergency Rescue Service is committed to compliance with the Health Insurance Accountability Act of 1996 (HIPPA) regarding privacy of Protected Health Information as defined by HIPPA. This ruling applies to all TIERS members and employees.

 

Medical Authorization / Assignment of Benefits

I have read and agree to all terms and conditions of SAFEGUARDTM Subscription Agreement. I authorize any holder of medical records or other information about me or my dependents to release to my insurance company, Health Care Financing Administration, Medicare or any of their agents, any information needed to determine benefits for services provided by TIERS. I request payment of authorized benefits be made on my behalf to TIERS, for any services provided to my dependents or me by TIERS.

 

MAIN SUBSCRIBER INFORMATION                                                  ADDITIONAL MEMBER INFORMATION

 

NAME _____________________________________________        ADDRESS __________________________________________      

 

CITY _____________________________________________           STATE _____________ ZIP CODE ______________________      

 

TELEPHONE(S):  ____________________________________          E-MAIL: ____________________________________________________

 

SIGN HERE: _________________________________________        SIGN HERE: _________________________________________________

 

DATE HERE: ________________________                                          DATE HERE: ___________________________

 

 

 

▪Please print clearly. Refer to any personal records or insurance cards which may help you provide complete information.

▪If you have any questions, please call TIERS at (315) 686-3510 or 686–2058.   

▪Payment in full MUST accompany completed application. 

▪Make check or money order out to:  

                                                                                  Thousand Islands Emergency Rescue Service, Inc.  

▪MAIL TO, OR DROP OFF AT:                                 P.O. Box 524

                                                                                  100 Union Street

                                                                                  Clayton, NY   13624

 

 

                                                                                     

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