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| Business Office 1115 South Benton Street Searcy, Arkansas 72143 501-305-2287 Local 866-305-2287 Toll-free 501-268-7026 Fax 501-268-2353 Administration |
NorthStar EMS offers Individual and Family Memberships. Family memberships include head of household, spouse,
and unmarried children under age 22 still living at home or under 24 if full time students. Membership purchase
affirms that you have read, understand and agree to the following terms and conditions:
This is NOT an insurance policy or supplement.
Membership fees are nonrefundable / nontransferable. Annual enrollment drives are conducted April 1 - May 31. All
White & Cleburne County memberships expire May 31st. Fees are not prorated when joining outside the enrollment
period, and such memberships will expire on May 31 of the membership year.
MEDICAL NECESSITY - Ambulance service must be medically necessary, usually as determined by a physician.
NorthStar EMS reserves the right to determine medical necessity for non-emergency service. Emergency transports
are limited to situations in which a member has sustained injury, sudden illness or trauma and the need for the
immediate medical attention of a doctor at a hospital emergency room exists. Non-emergency transportation excludes
such immediate, life threatening needs and may require physician authorization and/or a Physician Certification
Statement (PCS) form as a condition of transport.
COVERAGE - Ambulance transportation (emergency & non-emergency) is provided to and from HOSPITALS within
NorthStar’s service area. Patients are transported to the hospital of their choice; however, the physician or NorthStar
EMS may select an appropriate facility based on the patient’s medical condition. Emergencies and the need to provide
continuing service area coverage have first priority. All dispatching/staffing decisions are the sole right of NorthStar
EMS. Non-emergency services to and from medical facilities other than hospitals (e.g. doctor’s office, clinics, dentist,
freestanding dialysis, physical therapy, rehab) require medical necessity and are subject to the member discount
privileges below.
“MEMBER’S CHOICE” / OTHER PROVIDERS - Membership benefits are not guaranteed unless ambulance service is
provided by NorthStar EMS. To receive membership benefits, you may have to specify that NorthStar EMS be called. In
some areas, there are other ambulance providers, which may be automatically dispatched unless you request
NorthStar EMS. Members are encouraged to make the dispatcher and others arranging ambulance transportation
aware of their membership benefits and to specify NorthStar EMS for transport.
!! IMPORTANT !! MEMBER PAYMENTS / MEMBER DISCOUNTS - Membership DOES NOT guarantee no out-of-pocket
expense for ambulance service. Where benefits are available, NorthStar EMS will accept the amount paid as payment
in full. When there is NO medical, health insurance or other benefits plan which pays for ambulance service, the
member will receive a discounted ambulance bill [40% off the total charges] and shall be responsible for payment
directly to NorthStar EMS. NorthStar EMS agrees to pursue all payer sources prior to billing the member the
discounted rate. The discounted rate may apply transports even if physician authorized.
ASSIGNMENT / THIRD PARTY REIMBURSEMENT - Members assign to NorthStar EMS all rights and benefits under any
and all medical or health insurance policies or plans and all other medical benefits programs or plans which provide
ambulance coverage. Further, members authorize holders of any information about them to release it to HCFA, its
Carriers or agents, and to NorthStar EMS now or in the future. Any payments made directly to the member must be
turned over to NorthStar EMS in full, immediately. Failure to provide necessary information concerning available
insurance or medical benefits, or failure to forward any amount paid for ambulance service shall result in revocation of
membership. NorthStar EMS will file with all available policies or plans its claim for each ambulance service, and
further agrees to accept the amount paid as payment in full up to the amount of the charges.
NEW GUIDELINES - Many skilled nursing facilities are subject to Consolidated Billing and Prospective Payment
System (CB/PPS) guidelines imposed by HCFA and the Federal government. Membership with NorthStar EMS does
not exclude any facility where a member may reside from payment under the CB/PPS guidelines. Membership is not
transferable to contracts with facilities without prior authorization by NorthStar EMS.
Notice to persons with only MEDICAID coverage: Joining a membership program is voluntary and is discouraged.
You already have all benefits for covered services.
| Membership Terms |