Common use of DD YYYY Clause in Contracts

DD YYYY. Sex: Male Female (Choose One) Phone: - - Alt Phone Email: Home Address (must be within an AFMA Ambulance Service Area) Facility Name (Optional): Street Address: Mailing Address (If different from above): City: State: Zip Code: Primary Insurance Carrier Name: Policy/Subscriber/Insured #: Group #: Claim Mailing: Address: City: State: Zip Code: Secondary Insurance Carrier Name: Policy/Subscriber/Insured #: Group #: Claim Mailing: Address: City: State: Zip Code: SPOUSE DEPENDENT CHILD OTHER Name: Social Security Number: - - Date of Birth: - - Sex: Male Female (Choose One) Phone: - - Alt Phone: - - Email: Primary Insurance Carrier Name: Policy/Subscriber/Insured #: Group #: Claim Mailing: Address: City: State: Zip Code: Secondary Insurance Carrier Name: Policy/Subscriber/Insured #: Group #: Claim Mailing: Address: City: State: Zip Code: SPOUSE DEPENDENT CHILD OTHER SPOUSE DEPENDENT CHILD OTHER Name: Social Security Number: - - Date of Birth: - - Sex: Male Female (Choose One)) Phone: - - Alt Phone: - - Email: Primary Insurance Carrier Name: Policy/Subscriber/Insured #: Group #: Claim Mailing: Address: City: State: Zip Code: Secondary Insurance Carrier Name: Policy/Subscriber/Insured #: Group #: Claim Mailing: Address: City: State: Zip Code: Name: Social Security Number: - - Date of Birth: - - Sex: Male Female (Choose One) Phone: - - Alt Phone: - - Email: Primary Insurance Carrier Name: Policy/Subscriber/Insured #: Group #: Claim Mailing: Address: City: State: Zip Code: Secondary Insurance Carrier Name: Policy/Subscriber/Insured #: Group #: Claim Mailing: Address: City: State: Zip Code: SPOUSE DEPENDENT CHILD OTHER Name: Social Security Number: - - Date of Birth: - - Sex: Male Female (Choose One) Phone: - - Alt Phone: - - Email: Primary Insurance Carrier Name: Policy/Subscriber/Insured #: Group #: Claim Mailing: Address: City: State: Zip Code: Secondary Insurance Carrier Name: Policy/Subscriber/Insured #: Group #: Claim Mailing: Address: City: State: Zip Code: ARIZONA FIRE & MEDICAL AUTHORITY ☐ Check/Money Order for $75.00 Made Payable to: Arizona Fire & Medical Authority ☐ Visa ☐ Mastercard Expiration Date / Security Code - - -

DD YYYY. Sex: ☐ Male ☐ Female (Choose Onechoose one) PhoneTelephone Number: - - Alt Phone Email: Alternate Number Home Address (must be within an AFMA Ambulance Service Area) Facility Name (Optionaloptional): Street Address: Mailing Address (If different from above): City: State: Zip Code: Primary Insurance Carrier Name: Policy/Subscriber/Insured #: Group #: Claim Mailing: Address: City: State: Zip Code: Secondary Insurance Carrier Name: Policy/Subscriber/Insured #: Group #: Claim Mailing: Address: City: State: Zip Code: SPOUSE DEPENDENT CHILD OTHER Relationship to Primary Contact: ☐ Spouse ☐ Dependent ☐ Child ☐ Other Name: Date of Birth: Sex: ☐ Male ☐ Female (choose one) Social Security Number Telephone Number: - - Date of Birth: - - Sex: Male Female (Choose One) Phone: - - Alt Phone: - - Email: Primary Insurance Carrier Name: Alternate Number Policy/Subscriber/Insured #: Group #: Claim Mailing: Mailing Address: City: State: Zip CodeZip: Secondary Insurance Carrier Name: Policy/Subscriber/Insured #: Group #: Claim Mailing: Mailing Address: City: State: Zip CodeZip: SPOUSE DEPENDENT CHILD OTHER SPOUSE DEPENDENT CHILD OTHER Signature Relationship to Primary Contact: ☐ Spouse ☐ Dependent ☐ Child ☐ Other Name: Date of Birth: Sex: ☐ Male ☐ Female (choose one) Social Security Number Telephone Number: - - Date of Birth: - - Sex: Male Female (Choose One)) Phone: - - Alt Phone: - - Email: Primary Insurance Carrier Name: Alternate Number Policy/Subscriber/Insured #: Group #: Claim Mailing: Mailing Address: City: State: Zip CodeZip: Secondary Insurance Carrier Name: Policy/Subscriber/Insured #: Group #: Claim Mailing: Mailing Address: City: State: Zip CodeZip: Name: Social Security Number: - - Date of Birth: - - Sex: Male Female (Choose One) Phone: - - Alt Phone: - - Email: Primary Insurance Carrier Name: Policy/Subscriber/Insured #: Group #: Claim Mailing: Address: City: State: Zip Code: Secondary Insurance Carrier Name: Policy/Subscriber/Insured #: Group #: Claim Mailing: Address: City: State: Zip Code: SPOUSE DEPENDENT CHILD OTHER Name: Social Security Number: - - Date of Birth: - - Sex: Male Female (Choose One) Phone: - - Alt Phone: - - Email: Primary Insurance Carrier Name: Policy/Subscriber/Insured #: Group #: Claim Mailing: Address: City: State: Zip Code: Secondary Insurance Carrier Name: Policy/Subscriber/Insured #: Group #: Claim Mailing: Address: City: State: Zip Code: ARIZONA FIRE & MEDICAL AUTHORITY Signature ☐ Check/Money Order for $75.00 Made Payable to: Arizona Fire & Medical Authority ☐ Check here if you would like to have your membership renewed annually. • If paying by check, an invoice will be mailed annually. • If paying by credit or debit card, your card will automatically be charged each year. ☐ Visa ☐ Mastercard Expiration Date / Security Code - - -Name on Card Address City, State, Zip Telephone Number Cardholder Signature Include this completed form and check (if applicable) with your signed Ambulance Membership Program Agreement and your completed Ambulance Membership Program Form. Mail to: Arizona Fire & Medical Authority 18818 N. Spanish Garden Dr. Sun City West, AZ 85375 A confirmation of your approved membership agreement and a receipt of payment will be mailed to the above address within 30 days, but coverage will be effective on the date your completed subscription agreement and fee are received and approved by the Authority. This Notice of Privacy Practices (''Notice") describes the legal duties of the Arizona Fire & Medical Authority ("Provider," "we," "us," or "our") and your legal rights regarding your protected health information ("PHI") in accordance with the Health Insurance Portability and Accountability Act of 1996, as amended ("HIPAA"). • Maintain the privacy of your PHI; • Provide you with certain rights with respect to your PHI; • Provide you with a copy of this Notice of our legal duties and privacy practices with respect to your PHI; and • Follow the terms of the Notice that is currently in effect.