Membership applies to resident who live and work in the 10 communities we service: Middlebury, Bridport, Cornwall, Orwell, Ripton, Salisbury, Shoreham, Weybridge, Whiting, and parts of New Haven.
We bill your insurance company directly. Your membership is not an insurance policy—it covers any outstanding fees that your insurance carrier does not cover. It applies only to 911 Emergency transport and does not apply to interfacilty transfers.
I hereby apply for the Middlebury Regional EMS (MREMS) service subscription membership program as indicated on the reverse side of this form. I understand that the indicated fee provides local emergency ambulance services to members and their registered associates as indicated and qualified, and as determined to be medically necessary within the service area of MREMS at no additional cost during the time of the prescribed agreement (MREMS fiscal year period of July 1 to June 30). I also understand that this membership permits MREMS to collect directly from any third party agency whatever benefits may be available at no charge to me, my family, or my constituents, and that this membership is non-refundable and non-transferrable. I request that any payment of any authorized insurance benefits be made on my behalf to MREMS for any services furnished by this health care provider or supplier. I authorize any holder of medical information about me to be released to the Health Care Financing Administration and its agents any information needed to determine these benefits payable for related services.
