Common use of Limitations and Conditions Clause in Contracts

Limitations and Conditions. Membership benefits only extend to AMR’s advanced or basic life support ambulance services staffed with paramedics and EMT/Is, and EMTs. Membership benefits are inapplicable to services rendered by any other provider. As a condition of receiving the benefits of membership with respect to any ambulance transport, a member with insurance must comply with all coverage conditions of the applicable insurance program for such transport. Some insurance programs require the insured person to obtain prior authorization of payment for non-emergency, yet medically neces- sary ambulance services. Some plans require certain documentation from the insured with a specified time limit, or the plans deny or reduce coverage for ambulance services. In the event a member with insurance forfeits coverage by failing to comply with these types of requirements for a transport that would otherwise be covered by membership, or the services are denied as covered, then AMR shall provide the member with a 50% discount of its usual and customary charge for such transport. Non-insured household family members will receive a 50% discount for services rendered. Membership only covers ambulance services that begin in Xxxxx County and terminate in the service area(s):Xxxxx County, Arlington, Fort Worth, & Dallas hospitals. No benefits are provided for services rendered outside of these areas. I agree to pay AMR for any services it provides that are not covered by the membership benefit at 100% usual customary rates for non- medically necessary transports. AMR reserves sole discretion to deny or revoke membership and to refund membership fees (in full or in part) for reasonable cause, includ- ing but not limited to failure to comply with the terms of this Agreement. If AMR revokes my membership, I will pay all balances in full. AMR reserves the right to discontinue its membership program at any time upon notice to members. In such event, AMR shall return a pro- rated portion of the membership fee. AMR also reserves the right to unilaterally modify the terms of membership. AMR may assign its right or duties under this agreement. AMKT3-1134 If you have no insurance, or your insurance denies your medically necessary claim, AMR will bill you for 50% of the usual and customary charges. All family members, up to the age of 26 years or younger, living at your residence are covered under one membership, provided they are listed below. We will complete all necessary paperwork, file claim and negotiate with your insurance company. Memberships are effective from the month you sign up through January 2, 2020 Do not send cash. Make check or money order payable to AMR (American Medical Response). PLEASE ATTACH COPIES OF BOTH THE FRONT AND BACK OF ALL YOUR PRIMARY AND SECONDARY INSURANCE CARDS. Janurary 3, 2019 - Janurary 2, 2020 Please complete all information below and sign the Ambu-Care membership agreement. Return your completed form with your payment to AMR, Ambu-Care, 0000 X. XXX 000 Xxxxxxxx Xxxxxxxxxx,XX 00000, (000) 000-0000 Is this a Renewal or New Application? First Name Middle Initial Last Name Home Address City_ ZipCode Home Phone # Email Address @ SS # - - Date of Birth Male Female Primary Insurance Policy # Phone # Group # Insurance Company Address Supplemental Insurance Policy # Group # Supplemental Insurance Address Phone # Insured Employer Name Address Other Family Members of Household First Name Middle Initial Last Name SS # Date of Birth Male Female Primary Insurance Policy # Phone # Group # First Name Middle Initial Last Name SS # Date of Birth Male Female Primary Insurance Policy # Phone # Group # First Name Middle Initial Last Name SS # Date of Birth Male Female Primary Insurance Policy # Phone # Group # Do not send cash – make check or money order payable to AMR (American Medical Response) PLEASE ATTACH COPIES OF BOTH THE FRONT AND BACK OF ALL YOUR PRIMARY AND SECONDARY INSURANCE CARDS. All membership applicants 19 years of age or older must sign below with signature of other adult member.‌ I hereby apply for membership in the Xxxxx County Ambu-Care Membership program. I have reviewed the Ambu-Care Membership Agreement and agree to abide by the terms thereof. I request payment of authorized Medicare or other insurance benefits to me, or on my behalf, to be paid to AMR (American Medical Response), in order to determine benefits payable on my behalf, now and in the future. This agreement and authorization is executed on my own behalf and on behalf of the other members of my household, if they are minors or otherwise unable to sign. X Date X Date X Date

Limitations and Conditions. Membership benefits only extend to AMR’s advanced or basic life support ambulance services staffed with paramedics and EMT/Is, and EMTsEMT's. Membership benefits are inapplicable to services rendered by any other provider. As a condition of receiving the benefits of membership with respect to any ambulance transport, a member with insurance must comply with all coverage conditions of the applicable insurance program for such transport. Some insurance programs require the insured person to obtain prior authorization of payment for non-emergency, yet medically neces- sary ambulance services. Some plans require certain documentation from the insured with a specified time limit, or the plans deny or reduce coverage for ambulance services. In the event a member with insurance forfeits coverage by failing to comply with these types of requirements for a transport that would otherwise be covered by membership, or the services are denied as covered, then AMR shall provide the member with a 50% discount of its usual and customary charge for such transport. Non-insured household family members will receive a 50% discount for services rendered. Membership only covers ambulance services that begin in Xxxxx County and terminate in the service area(s):Xxxxx County, Arlington, Fort Worth, & Dallas hospitals. No benefits are provided for services rendered outside of these areas. I agree to pay AMR for any services it provides that are not covered by the membership benefit at 100% usual customary rates for non- medically necessary transports. AMR reserves sole discretion to deny or revoke membership and to refund membership fees (in full or in part) for reasonable cause, includ- ing including but not limited to failure to comply with the terms of this Agreement. If AMR revokes my membership, I will pay all balances in full. AMR reserves the right to discontinue its membership program at any time upon notice to members. In such event, AMR shall return a pro- pro-rated portion of the membership fee. AMR also reserves the right to unilaterally modify the terms of membership. AMR may assign its right or duties under this agreement. AMKT3-1134 If you have no insurance, or your insurance denies your medically necessary claim, AMR will bill you for 50% of the usual and customary charges. All family members, up to the age of 26 years or younger, living at your residence are covered under one membership, provided they are listed below. We will complete all necessary paperwork, file claim and negotiate with your insurance company. Memberships are effective from the month you sign up through January 2, 2020 2021 Do not send cash. Make check or money order payable to AMR (American Medical Response). PLEASE ATTACH COPIES OF BOTH THE FRONT AND BACK OF ALL YOUR PRIMARY AND SECONDARY INSURANCE CARDS. Janurary 3, 2019 2020 - Janurary 2, 2020 2021 Please complete all information below and sign the Ambu-Care membership agreement. Return your completed form with your payment to AMR, Ambu-Care, 0000 X. XXX 000 Xxxxxxxx Xxxxxxxxxx,XX 00000, (000) 000-0000 Is this a Renewal or New Application? First Name Middle Initial Last Name Home Address City_ ZipCode Home Phone # Email Address @ SS # - - Date of Birth Male Female Primary Insurance Policy # Phone # Group # Insurance Company Address Supplemental Insurance Policy # Group # Supplemental Insurance Address Phone # Insured Employer Name Address Other Family Members of Household First Name Middle Initial Last Name SS # Date of Birth Male Female Primary Insurance Policy # Phone # Group # First Name Middle Initial Last Name SS # Date of Birth Male Female Primary Insurance Policy # Phone # Group # First Name Middle Initial Last Name SS # Date of Birth Male Female Primary Insurance Policy # Phone # Group # Do not send cash – make check or money order payable to AMR (American Medical Response) PLEASE ATTACH COPIES OF BOTH THE FRONT AND BACK OF ALL YOUR PRIMARY AND SECONDARY INSURANCE CARDS. All membership applicants 19 years of age or older must sign below with signature of other adult member.‌ I hereby apply for membership in the Xxxxx County Ambu-Care Membership program. I have reviewed the Ambu-Care Membership Agreement and agree to abide by the terms thereof. I request payment of authorized Medicare or other insurance benefits to me, or on my behalf, to be paid to AMR (American Medical Response), in order to determine benefits payable on my behalf, now and in the future. This agreement and authorization is executed on my own behalf and on behalf of the other members of my household, if they are minors or otherwise unable to sign. X Date X Date X Date

Limitations and Conditions. Membership benefits only extend to AMR’s advanced or basic life support ambulance services staffed with paramedics and EMT/Is, and EMTs. Membership benefits are inapplicable to services rendered by any other provider. As a condition of receiving the benefits of membership with respect to any ambulance transport, a member with insurance must comply with all coverage conditions of the applicable insurance program for such transport. Some insurance programs require the insured person to obtain prior authorization of payment for non-emergency, yet medically neces- sary ambulance services. Some plans require certain documentation from the insured with a specified time limit, or the plans deny or reduce coverage for ambulance services. In the event a member with insurance forfeits coverage by failing to comply with these types of requirements for a transport that would otherwise be covered by membership, or the services are denied as covered, then AMR shall provide the member with a 50% discount of its usual and customary charge for such transport. Non-insured household family members will receive a 50% discount for services rendered. Membership only covers ambulance services that begin in Xxxxx County and terminate in the service area(s):Xxxxx County, Arlington, Fort Worth, & Dallas hospitals. No benefits are provided for services rendered outside of these areas. I agree to pay AMR for any services it provides that are not covered by the membership benefit at 100% usual customary rates for non- medically necessary transports. AMR reserves sole discretion to deny or revoke membership and to refund membership fees (in full or in part) for reasonable cause, includ- ing but not limited to failure to comply with the terms of this Agreement. If AMR revokes my membership, I will pay all balances in full. AMR reserves the right to discontinue its membership program at any time upon notice to members. In such event, AMR shall return a pro- rated portion of the membership fee. AMR also reserves the right to unilaterally modify the terms of membership. AMR may assign its right or duties under this agreement. AMKT3-1134 If you have no insurance, or your insurance denies your medically necessary claim, AMR will bill you for 50% of the usual and customary charges. All family members, up to the age of 26 years or younger, living at your residence are covered under one membership, provided they are listed below. We will complete all necessary paperwork, file claim and negotiate with your insurance company. Memberships are effective from the month you sign up through January 2, 2020 2021 Do not send cash. Make check or money order payable to AMR (American Medical Response). PLEASE ATTACH COPIES OF BOTH THE FRONT AND BACK OF ALL YOUR PRIMARY AND SECONDARY INSURANCE CARDS. Janurary Ambu-Care APPLICATION January 3, 2019 2020 - Janurary January 2, 2020 2021 Please complete all information below and sign the Ambu-Care membership agreement. Return your completed form with your payment to AMR, Ambu-Care, 0000 X. XXX 000 Xxxxxxxx Xxxxxxxxxx,XX 00000, (000) 000-0000 Is this a Renewal or New Application? First Name Middle Initial Last Name Home Address City_ ZipCode Home Phone # Email Address @ SS # - - Date of Birth Male Female Primary Insurance Policy # Phone # Group # Insurance Company Address Supplemental Insurance Policy # Group # Supplemental Insurance Address Phone # Insured Employer Name Address Other Family Members of Household First Name Middle Initial Last Name SS # Date of Birth Male Female Primary Insurance Policy # Phone # Group # First Name Middle Initial Last Name SS # Date of Birth Male Female Primary Insurance Policy # Phone # Group # First Name Middle Initial Last Name SS # Date of Birth Male Female Primary Insurance Policy # Phone # Group # Do not send cash – make check or money order payable to AMR (American Medical Response) PLEASE ATTACH COPIES OF BOTH THE FRONT AND BACK OF ALL YOUR PRIMARY AND SECONDARY INSURANCE CARDS. All membership applicants 19 years of age or older must sign below with signature of other adult member.‌ I hereby apply for membership in the Xxxxx County Ambu-Care Membership program. I have reviewed the Ambu-Care Membership Agreement and agree to abide by the terms thereof. I request payment of authorized Medicare or other insurance benefits to me, or on my behalf, to be paid to AMR (American Medical Response), in order to determine benefits payable on my behalf, now and in the future. This agreement and authorization is executed on my own behalf and on behalf of the other members of my household, if they are minors or otherwise unable to sign. X Date X Date X Date

Limitations and Conditions. Membership benefits only extend to AMR’s advanced or basic life support ambulance services staffed with paramedics and EMT/Is, and EMTs. Membership benefits are inapplicable to services rendered by any other provider. As a condition of receiving the benefits of membership with respect to any ambulance transport, a member with insurance must comply with all coverage conditions of the applicable insurance program for such transport. Some insurance programs require the insured person to obtain prior authorization of payment for non-emergency, yet medically neces- sary ambulance services. Some plans require certain documentation from the insured with a specified time limit, or the plans deny or reduce coverage for ambulance services. In the event a member with insurance forfeits coverage by failing to comply with these types of requirements for a transport that would otherwise be covered by membership, or the services are denied as covered, then AMR shall provide the member with a 50% discount of its usual and customary charge for such transport. Non-insured household family members will receive a 50% discount for services rendered. Membership only covers ambulance services that begin in Xxxxx Ellis County and terminate in the service area(s):Xxxxx area(s):Ellis County, Arlington, Fort Worth, & Dallas hospitals. No benefits are provided for services rendered outside of these areas. I agree to pay AMR for any services it provides that are not covered by the membership benefit at 100% usual customary rates for non- medically necessary transports. AMR reserves sole discretion to deny or revoke membership and to refund membership fees (in full or in part) for reasonable cause, includ- ing but not limited to failure to comply with the terms of this Agreement. If AMR revokes my membership, I will pay all balances in full. AMR reserves the right to discontinue its membership program at any time upon notice to members. In such event, AMR shall return a pro- rated portion of the membership fee. AMR also reserves the right to unilaterally modify the terms of membership. AMR may assign its right or duties under this agreement. AMKT3-1134 If you have no insurance, or your insurance denies your medically necessary claim, AMR will bill you for 50% of the usual and customary charges. All family members, up to the age of 26 years or younger, living at your residence are covered under one membership, provided they are listed below. We will complete all necessary paperwork, file claim and negotiate with your insurance company. Memberships are effective from the month you sign up through January 2, 2020 2019 Do not send cash. Make check or money order payable to AMR (American Medical Response). PLEASE ATTACH COPIES OF BOTH THE FRONT AND BACK OF ALL YOUR PRIMARY AND SECONDARY INSURANCE CARDS. Ambu-Care APPLICATION Janurary 3, 2019 2018 - Janurary 2, 2020 2019 Please complete all information below and sign the Ambu-Care membership agreement. Return your completed form with your payment to AMR, Ambu-Care, 0000 X. XXX 000 Xxxxxxxx Xxxxxxxxxx,XX 00000, (000) 000-0000 Is this a Renewal or New Application? First Name Middle Initial Last Name Home Address City_ ZipCode Home Phone # Email Address @ SS # - - Date of Birth Male Female Primary Insurance Policy # Phone # Group # Insurance Company Address Supplemental Insurance Policy # Group # Supplemental Insurance Address Phone # Insured Employer Name Address Other Family Members of Household First Name Middle Initial Last Name SS # Date of Birth Male Female Primary Insurance Policy # Phone # Group # First Name Middle Initial Last Name SS # Date of Birth Male Female Primary Insurance Policy # Phone # Group # First Name Middle Initial Last Name SS # Date of Birth Male Female Primary Insurance Policy # Phone # Group # Do not send cash – make check or money order payable to AMR (American Medical Response) PLEASE ATTACH COPIES OF BOTH THE FRONT AND BACK OF ALL YOUR PRIMARY AND SECONDARY INSURANCE CARDS. All membership applicants 19 years of age or older must sign below with signature of other adult member.‌ I hereby apply for membership in the Xxxxx Ellis County Ambu-Care Membership program. I have reviewed the Ambu-Care Membership Agreement and agree to abide by the terms thereof. I request payment of authorized Medicare or other insurance benefits to me, or on my behalf, to be paid to AMR (American Medical Response), in order to determine benefits payable on my behalf, now and in the future. This agreement and authorization is executed on my own behalf and on behalf of the other members of my household, if they are minors or otherwise unable to sign. X Date X Date X DateDate Signature of other adult member

Limitations and Conditions. Membership benefits only extend to AMR’s advanced or basic life support ambulance services staffed with paramedics and EMT/Is, and EMTs. Membership benefits are inapplicable to services rendered by any other provider. As a condition of receiving the benefits of membership with respect to any ambulance transport, a member with insurance must comply with all coverage conditions of the applicable insurance program for such transport. Some insurance programs require the insured person to obtain prior authorization of payment for non-emergency, yet medically neces- sary ambulance services. Some plans require certain documentation from the insured with a specified time limit, or the plans deny or reduce coverage for ambulance services. In the event a member with insurance forfeits coverage by failing to comply with these types of requirements for a transport that would otherwise be covered by membership, or the services are denied as covered, then AMR shall provide the member with a 50% discount of its usual and customary charge for such transport. Non-insured household family members will receive a 50% discount for services rendered. Membership only covers ambulance services that begin in Xxxxx Ellis County and terminate in the service area(s):Xxxxx area(s):Ellis County, Arlington, Fort Worth, & Dallas hospitals. No benefits are provided for services rendered outside of these areas. I agree to pay AMR for any services it provides that are not covered by the membership benefit at 100% usual customary rates for non- medically necessary transports. AMR reserves sole discretion to deny or revoke membership and to refund membership fees (in full or in part) for reasonable cause, includ- ing but not limited to failure to comply with the terms of this Agreement. If AMR revokes my membership, I will pay all balances in full. AMR reserves the right to discontinue its membership program at any time upon notice to members. In such event, AMR shall return a pro- rated portion of the membership fee. AMR also reserves the right to unilaterally modify the terms of membership. AMR may assign its right or duties under this agreement. AMKT3-1134 If you have no insurance, or your insurance denies your medically necessary claim, AMR will bill you for 50% of the usual and customary charges. All family members, up to the age of 26 years or younger, living at your residence are covered under one membership, provided they are listed below. We will complete all necessary paperwork, file claim and negotiate with your insurance company. Memberships are effective from the month you sign up through January 2, 2020 Do not send cash. Make check or money order payable to AMR (American Medical Response). PLEASE ATTACH COPIES OF BOTH THE FRONT AND BACK OF ALL YOUR PRIMARY AND SECONDARY INSURANCE CARDS. Janurary 3, 2019 - Janurary 2, 2020 Please complete all information below and sign the Ambu-Care membership agreement. Return your completed form with your payment to AMR, Ambu-Care, 0000 X. XXX 000 Xxxxxxxx Xxxxxxxxxx,XX 00000, (000) 000-0000 Is this a Renewal or New Application? First Name Middle Initial Last Name Home Address City_ ZipCode Home Phone # Email Address @ SS # - - Date of Birth Male Female Primary Insurance Policy # Phone # Group # Insurance Company Address Supplemental Insurance Policy # Group # Supplemental Insurance Address Phone # Insured Employer Name Address Other Family Members of Household First Name Middle Initial Last Name SS # Date of Birth Male Female Primary Insurance Policy # Phone # Group # First Name Middle Initial Last Name SS # Date of Birth Male Female Primary Insurance Policy # Phone # Group # First Name Middle Initial Last Name SS # Date of Birth Male Female Primary Insurance Policy # Phone # Group # Do not send cash – make check or money order payable to AMR (American Medical Response) PLEASE ATTACH COPIES OF BOTH THE FRONT AND BACK OF ALL YOUR PRIMARY AND SECONDARY INSURANCE CARDS. All membership applicants 19 years of age or older must sign below with signature of other adult member.‌ I hereby apply for membership in the Xxxxx Ellis County Ambu-Care Membership program. I have reviewed the Ambu-Care Membership Agreement and agree to abide by the terms thereof. I request payment of authorized Medicare or other insurance benefits to me, or on my behalf, to be paid to AMR (American Medical Response), in order to determine benefits payable on my behalf, now and in the future. This agreement and authorization is executed on my own behalf and on behalf of the other members of my household, if they are minors or otherwise unable to sign. X Date X Date X Date

Limitations and Conditions. Membership benefits only extend to AMR’s advanced or basic life support ambulance services staffed with paramedics and EMT/Is, and EMTs. Membership benefits are inapplicable to services rendered by any other provider. As a condition of receiving the benefits of membership with respect to any ambulance transport, a member with insurance must comply with all coverage conditions of the applicable insurance program for such transport. Some insurance programs require the insured person to obtain prior authorization of payment for non-emergency, yet medically neces- sary ambulance services. Some plans require certain documentation from the insured with a specified time limit, or the plans deny or reduce coverage for ambulance services. In the event a member with insurance forfeits coverage by failing to comply with these types of requirements for a transport that would otherwise be covered by membership, or the services are denied as covered, then AMR shall provide the member with a 50% discount of its usual and customary charge for such transport. Non-insured household family members will receive a 50% discount for services rendered. Membership only covers ambulance services that begin in Xxxxx County and terminate in the service area(s):Xxxxx County, Arlington, Fort Worth, & Dallas hospitalsDallas/Ft. Worth Metropolitan Area. No benefits are provided for services rendered outside of these areas. I agree to pay AMR for any services it provides that are not covered by the membership benefit at 100% usual customary rates for non- non-medically necessary transports. AMR reserves sole discretion to deny or revoke membership and to refund membership fees (in full or in part) for reasonable cause, includ- ing but not limited to failure to comply with the terms of this Agreement. If AMR revokes my membership, I will pay all balances in full. AMR reserves the right to discontinue its membership program at any time upon notice to members. In such event, AMR shall return a pro- pro-rated portion of the membership fee. AMR also reserves the right to unilaterally modify the terms of membership. AMR may assign its right or duties under this agreement. AMKT3-1134 023344AMKT31324500 If you have no insurance, or your insurance denies your medically necessary claim, AMR will bill you for 50% of the usual and customary charges. All family members, up to the age of 26 years or younger, living at your residence are covered under one membership, provided they are listed below. We will complete all necessary paperwork, file claim and negotiate with your insurance company. Memberships are effective from the month you sign up January 3, 2017 through January 2, 2020 2018 Do not send cash. Make check or money order payable to AMR (American Medical Response). PLEASE ATTACH COPIES OF BOTH THE FRONT AND BACK OF ALL YOUR PRIMARY AND SECONDARY INSURANCE CARDS. Janurary Ambu-Care APPLICATION January 3, 2019 2017 - Janurary January 2, 2020 2018 Please complete all information below and sign the Ambu-Care membership agreement. Return your completed form with your payment to AMR, Ambu-Care, 0000 X. XXX Xxx 000 Xxxxxxxx Xxxxx X, Xxxxxxxxxx,, XX 00000, (000) 000-0000 Is this a Renewal or New Application? First Name Middle Initial Last Name Home Address City_ ZipCode Address: City ZipCode: Home Phone # Email Address Address: @ SS # #: - - Date of Birth Birth: Male Female Primary Insurance Policy # #: Phone # #: Group # #: Insurance Company Address Address: Supplemental Insurance Policy # #: Group # #: Supplemental Insurance Address Address: Phone # #: Insured Employer Name Address Name: Address: Other Family Members of Household First Name Middle Initial Last Name SS # #: Date of Birth Birth: Male Female Primary Insurance Policy # #: Phone # #: Group # #: First Name Middle Initial Last Name SS # #: Date of Birth Birth: Male Female Primary Insurance Policy # #: Phone # #: Group # #: First Name Middle Initial Last Name SS # #: Date of Birth Birth: Male Female Primary Insurance Policy # #: Phone # #: Group # #: Do not send cash – make check or money order payable to AMR (American Medical Response) PLEASE ATTACH COPIES OF BOTH THE FRONT AND BACK OF ALL YOUR PRIMARY AND SECONDARY INSURANCE CARDS. All membership applicants 19 years of age or older must sign below with signature of other adult member.‌ member. I hereby apply for membership in the Xxxxx County Ambu-Care Membership program. I have reviewed the Ambu-Care Membership Agreement and agree to abide by the terms thereof. I request payment of authorized Medicare or other insurance benefits to me, or on my behalf, to be paid to AMR (American Medical Response), in order to determine benefits payable on my behalf, now and in the future. This agreement and authorization is executed on my own behalf and on behalf of the other members of my household, if they are minors or otherwise unable to sign. X Date X Date X DateDate Signature of other adult member

Limitations and Conditions. Membership benefits only extend to AMR’s advanced or basic life support ambulance services staffed with paramedics and EMT/Is, and EMTs. Membership benefits are inapplicable to services rendered by any other provider. As a condition of receiving the benefits of membership with respect to any ambulance transport, a member with insurance must comply with all coverage conditions of the applicable insurance program for such transport. Some insurance programs require the insured person to obtain prior authorization of payment for non-emergency, yet medically neces- sary ambulance services. Some plans require certain documentation from the insured with a specified time limit, or the plans deny or reduce coverage for ambulance services. In the event a member with insurance forfeits coverage by failing to comply with these types of requirements for a transport that would otherwise be covered by membership, or the services are denied as covered, then AMR shall provide the member with a 50% discount of its usual and customary charge for such transport. Non-insured household family members will receive a 50% discount for services rendered. Membership only covers ambulance services that begin in Xxxxx County and terminate in the service services area(s):Xxxxx County, Arlington, Fort Worth, & Dallas hospitals. No benefits are provided for services rendered outside of these areas. I agree to pay AMR for any services it provides that are not covered by the membership benefit at 100% usual customary rates for non- medically necessary transports. AMR reserves sole discretion to deny or revoke membership and to refund membership fees (in full or in part) for reasonable cause, includ- ing but not limited to failure to comply with the terms of this Agreement. If AMR revokes my membership, I will pay all balances in full. AMR reserves the right to discontinue its membership program at any time upon notice to members. In such event, AMR shall return a pro- pro-rated portion of the membership fee. AMR also reserves the right to unilaterally modify the terms of membership. AMR may assign its right or duties under this agreement. AMKT3-1134 If you have no insurance, or your insurance denies your medically necessary claim, AMR will bill you for 50% of the usual and customary charges. All family members, up to the age of 26 years or younger, living at your residence are covered under one membership, provided they are listed below. We will complete all necessary paperwork, file claim and negotiate with your insurance company. Memberships are effective from the month you sign up Janruary 3, 2016 through January 2, 2020 2017 Open enrollment period is October 1- December 31, 2015 Do not send cash. Make check or money order payable to AMR (American Medical Response). PLEASE ATTACH COPIES OF BOTH THE FRONT AND BACK OF ALL YOUR PRIMARY AND SECONDARY INSURANCE CARDS. Janurary 3Ambu-Care APPLICATION October 1, 2019 2015 - Janurary 2December 31, 2020 2015 Please complete all information below and sign the Ambu-Care membership agreement. Return your completed form with your payment to AMR, Ambu-Care, 0000 X. XXX 000 Xxxxxxxx Xxxxxxxxxx,XX 00000Xxxxxx Xxxx, Red Oak, TX 75154-5119, (000) 000-0000 Is this a Renewal or New Application? First Name Middle Initial Last Name Home Address City_ ZipCode Address: City ZipCode: Home Phone # Email Address Address: @ SS # - - Primary Insurance Date of Birth Birth: Male Female Primary Insurance Policy # #: Phone # #: Group # #: Insurance Company Address Address: Supplemental Insurance Policy # #: Group # #: Supplemental Insurance Address Address: Phone # #: Insured Employer Name Address Name: Address: Other Family Members of Household First Name Middle Initial Last Name SS # #: Date of Birth Birth: Male Female Primary Insurance Policy # #: Phone # #: Group # #: First Name Middle Initial Last Name SS # #: Date of Birth Birth: Male Female Primary Insurance Policy # #: Phone # #: Group # #: First Name Middle Initial Last Name SS # #: Date of Birth Birth: Male Female Primary Insurance Policy # #: Phone # #: Group # #: Do not send cash – make check or money order payable to AMR (American Medical Response) PLEASE ATTACH COPIES OF BOTH THE FRONT AND BACK OF ALL YOUR PRIMARY AND SECONDARY INSURANCE CARDS. All membership applicants 19 years of age or older must sign below with signature of other adult member.‌ member. I hereby apply for membership in the Xxxxx County Ambu-Care Membership program. I have reviewed the Ambu-Care Membership Agreement and agree to abide by the terms thereof. I request payment of authorized Medicare or other insurance benefits to me, or on my behalf, to be paid to AMR (American Medical Response), in order to determine benefits payable on my behalf, now and in the future. This agreement and authorization is executed on my own behalf and on behalf of the other members of my household, if they are minors or otherwise unable to sign. X Date X Date X DateDate Signature of other adult member **Within 30 days of receipt of the completed application and fee, members will receive correspondence from AMR confirming that their appliction and fee have been processed. Ambu Care Pro-Rated Fee Table‌ Sign up Month Insurance Coverage Initial Fee Amount Redudced Total To Pay Janaury 2016 Primary Insurance Only $67.50 $0.00 $67.50 Primary & Secondary Insurance $60.00 $0.00 $60.00 Feb-16 Primary Insurance Only $67.50 $5.63 $61.88 Primary & Secondary Insurance $60.00 $5.00 $55.00 March 2016 Primary Insurance Only $67.50 $11.25 $56.25 Primary & Secondary Insurance $60.00 $10.00 $50.00 April 2016 Primary Insurance Only $67.50 $16.88 $50.63 Primary & Secondary Insurance $60.00 $15.00 $45.00 May 2016 Primary Insurance Only $67.50 $22.50 $45.00 Primary & Secondary Insurance $60.00 $20.00 $40.00 June 2016 Primary Insurance Only $67.50 $28.13 $39.38 Primary & Secondary Insurance $60.00 $25.00 $35.00 July 2016 Primary Insurance Only $67.50 $33.75 $33.75 Primary & Secondary Insurance $60.00 $30.00 $30.00 August 2016 Primary Insurance Only $67.50 $39.38 $28.13 Primary & Secondary Insurance $60.00 $35.00 $25.00 September 2016 Primary Insurance Only $67.50 $45.00 $22.50 Primary & Secondary Insurance $60.00 $40.00 $20.00 October 2016 Primary Insurance Only $67.50 $50.63 $16.88 Primary & Secondary Insurance $60.00 $45.00 $15.00 November 2016 Primary Insurance Only $67.50 $56.25 $11.25 Primary & Secondary Insurance $60.00 $50.00 $10.00

Limitations and Conditions. Membership benefits only extend to AMR’s advanced or basic life support ambulance services staffed with paramedics and EMT/Is, and EMTs. Membership benefits are inapplicable to services rendered by any other provider. As a condition of receiving the benefits of membership with respect to any ambulance transport, a member with insurance must comply with all coverage conditions of the applicable insurance program for such transport. Some insurance programs require the insured person to obtain prior authorization of payment for non-emergency, yet medically neces- sary ambulance services. Some plans require certain documentation from the insured with a specified time limit, or the plans deny or reduce coverage for ambulance services. In the event a member with insurance forfeits coverage by failing to comply with these types of requirements for a transport that would otherwise be covered by membership, or the services are denied as covered, then AMR shall provide the member with a 50% discount of its usual and customary charge for such transport. Non-insured household family members will receive a 50% discount for services rendered. Membership only covers ambulance services that begin in Xxxxx County and terminate in the service services area(s):Xxxxx County, Arlington, Fort Worth, & Dallas hospitals. No benefits are provided for services rendered outside of these areas. I agree to pay AMR for any services it provides that are not covered by the membership benefit at 100% usual customary rates for non- medically necessary transports. AMR reserves sole discretion to deny or revoke membership and to refund membership fees (in full or in part) for reasonable cause, includ- ing but not limited to failure to comply with the terms of this Agreement. If AMR revokes my membership, I will pay all balances in full. AMR reserves the right to discontinue its membership program at any time upon notice to members. In such event, AMR shall return a pro- pro-rated portion of the membership fee. AMR also reserves the right to unilaterally modify the terms of membership. AMR may assign its right or duties under this agreement. AMKT3-1134 If you have no insurance, or your insurance denies your medically necessary claim, AMR will bill you for 50% of the usual and customary charges. All family members, up to the age of 26 years or younger, living at your residence are covered under one membership, provided they are listed below. We will complete all necessary paperwork, file claim and negotiate with your insurance company. Memberships are effective from the month you sign up Janruary 3, 2016 through January 2, 2020 2017 Open enrollment period is October 1- December 31, 2015 Do not send cash. Make check or money order payable to AMR (American Medical Response). PLEASE ATTACH COPIES OF BOTH THE FRONT AND BACK OF ALL YOUR PRIMARY AND SECONDARY INSURANCE CARDS. Janurary 3Ambu-Care APPLICATION October 1, 2019 2015 - Janurary 2December 31, 2020 2015 Please complete all information below and sign the Ambu-Care membership agreement. Return your completed form with your payment to AMR, Ambu-Care, 0000 X. XXX 000 Xxxxxxxx Xxxxxxxxxx,XX 00000Xxxxxx Xxxx, Red Oak, TX 75154-5119, (000) 000-0000 Is this a Renewal or New Application? First Name Middle Initial Last Name Home Address City_ ZipCode Address: City ZipCode: Home Phone # Email Address Address: @ SS # - - Primary Insurance Date of Birth Birth: Male Female Primary Insurance Policy # #: Phone # #: Group # #: Insurance Company Address Address: Supplemental Insurance Policy # #: Group # #: Supplemental Insurance Address Address: Phone # #: Insured Employer Name Address Name: Address: Other Family Members of Household First Name Middle Initial Last Name SS # #: Date of Birth Birth: Male Female Primary Insurance Policy # #: Phone # #: Group # #: First Name Middle Initial Last Name SS # #: Date of Birth Birth: Male Female Primary Insurance Policy # #: Phone # #: Group # #: First Name Middle Initial Last Name SS # #: Date of Birth Birth: Male Female Primary Insurance Policy # #: Phone # #: Group # #: Do not send cash – make check or money order payable to AMR (American Medical Response) PLEASE ATTACH COPIES OF BOTH THE FRONT AND BACK OF ALL YOUR PRIMARY AND SECONDARY INSURANCE CARDS. All membership applicants 19 years of age or older must sign below with signature of other adult member.‌ member. I hereby apply for membership in the Xxxxx County Ambu-Care Membership program. I have reviewed the Ambu-Care Membership Agreement and agree to abide by the terms thereof. I request payment of authorized Medicare or other insurance benefits to me, or on my behalf, to be paid to AMR (American Medical Response), in order to determine benefits payable on my behalf, now and in the future. This agreement and authorization is executed on my own behalf and on behalf of the other members of my household, if they are minors or otherwise unable to sign. X Date X Date X DateDate Signature of other adult member

Limitations and Conditions. Membership benefits only extend to AMR’s advanced or basic life support ambulance services staffed with paramedics and EMT/Is, and EMTsEMT's. Membership benefits are inapplicable to services rendered by any other provider. As a condition of receiving the benefits of membership with respect to any ambulance transport, a member with insurance must comply with all coverage conditions of the applicable insurance program for such transport. Some insurance programs require the insured person to obtain prior authorization of payment for non-emergency, yet medically neces- sary ambulance services. Some plans require certain documentation from the insured with a specified time limit, or the plans deny or reduce coverage for ambulance services. In the event a member with insurance forfeits coverage by failing to comply with these types of requirements for a transport that would otherwise be covered by membership, or the services are denied as covered, then AMR shall provide the member with a 50% discount of its usual and customary charge for such transport. Non-insured household family members will receive a 50% discount for services rendered. Membership only covers ambulance services that begin in Xxxxx Ellis County and terminate in the service area(s):Xxxxx area(s):Ellis County, Arlington, Fort Worth, & Dallas hospitals. No benefits are provided for services rendered outside of these areas. I agree to pay AMR for any services it provides that are not covered by the membership benefit at 100% usual customary rates for non- medically necessary transports. AMR reserves sole discretion to deny or revoke membership and to refund membership fees (in full or in part) for reasonable cause, includ- ing including but not limited to failure to comply with the terms of this Agreement. If AMR revokes my membership, I will pay all balances in full. AMR reserves the right to discontinue its membership program at any time upon notice to members. In such event, AMR shall return a pro- pro-rated portion of the membership fee. AMR also reserves the right to unilaterally modify the terms of membership. AMR may assign its right or duties under this agreement. AMKT3-1134 If you have no insurance, or your insurance denies your medically necessary claim, AMR will bill you for 50% of the usual and customary charges. All family members, up to the age of 26 years or younger, living at your residence are covered under one membership, provided they are listed below. We will complete all necessary paperwork, file claim and negotiate with your insurance company. Memberships are effective from the month you sign up through January 2, 2020 2022 Do not send cash. Make check or money order payable to AMR (American Medical Response). PLEASE ATTACH COPIES OF BOTH THE FRONT AND BACK OF ALL YOUR PRIMARY AND SECONDARY INSURANCE CARDS. Janurary 3, 2019 2021 - Janurary 2, 2020 2022 Please complete all information below and sign the Ambu-Care membership agreement. Return your completed form with your payment to AMR, Ambu-Care, 0000 X. XXX 000 Xxxxxxxx Xxxxxxxxxx,XX 00000, (000) 000-0000 Is this a Renewal or New Application? First Name Middle Initial Last Name Home Address City_ ZipCode Home Phone # Email Address @ SS # - - Date of Birth Male Female Primary Insurance Policy # Phone # Group # Insurance Company Address Supplemental Insurance Policy # Group # Supplemental Insurance Address Phone # Insured Employer Name Address Other Family Members of Household First Name Middle Initial Last Name SS # Date of Birth Male Female Primary Insurance Policy # Phone # Group # First Name Middle Initial Last Name SS # Date of Birth Male Female Primary Insurance Policy # Phone # Group # First Name Middle Initial Last Name SS # Date of Birth Male Female Primary Insurance Policy # Phone # Group # Do not send cash – make check or money order payable to AMR (American Medical Response) PLEASE ATTACH COPIES OF BOTH THE FRONT AND BACK OF ALL YOUR PRIMARY AND SECONDARY INSURANCE CARDS. All membership applicants 19 years of age or older must sign below with signature of other adult member.‌ I hereby apply for membership in the Xxxxx Ellis County Ambu-Care Membership program. I have reviewed the Ambu-Care Membership Agreement and agree to abide by the terms thereof. I request payment of authorized Medicare or other insurance benefits to me, or on my behalf, to be paid to AMR (American Medical Response), in order to determine benefits payable on my behalf, now and in the future. This agreement and authorization is executed on my own behalf and on behalf of the other members of my household, if they are minors or otherwise unable to sign. X Date X Date X Date

Limitations and Conditions. Membership benefits only extend to AMR’s advanced or basic life support ambulance services staffed with paramedics and EMT/Is, and EMTsEMT's. Membership benefits are inapplicable to services rendered by any other provider. As a condition of receiving the benefits of membership with respect to any ambulance transport, a member with insurance must comply with all coverage conditions of the applicable insurance program for such transport. Some insurance programs require the insured person to obtain prior authorization of payment for non-emergency, yet medically neces- sary ambulance services. Some plans require certain documentation from the insured with a specified time limit, or the plans deny or reduce coverage for ambulance services. In the event a member with insurance forfeits coverage by failing to comply with these types of requirements for a transport that would otherwise be covered by membership, or the services are denied as covered, then AMR shall provide the member with a 50% discount of its usual and customary charge for such transport. Non-insured household family members will receive a 50% discount for services rendered. Membership only covers ambulance services that begin in Xxxxx County and terminate in the service area(s):Xxxxx County, Arlington, Fort Worth, & Dallas hospitals. No benefits are provided for services rendered outside of these areas. I agree to pay AMR for any services it provides that are not covered by the membership benefit at 100% usual customary rates for non- medically necessary transports. AMR reserves sole discretion to deny or revoke membership and to refund membership fees (in full or in part) for reasonable cause, includ- ing including but not limited to failure to comply with the terms of this Agreement. If AMR revokes my membership, I will pay all balances in full. AMR reserves the right to discontinue its membership program at any time upon notice to members. In such event, AMR shall return a pro- pro-rated portion of the membership fee. AMR also reserves the right to unilaterally modify the terms of membership. AMR may assign its right or duties under this agreement. AMKT3-1134 If you have no insurance, or your insurance denies your medically necessary claim, AMR will bill xxxx you for 50% of the usual and customary charges. All family members, up to the age of 26 years or younger, living at your residence are covered under one membership, provided they are listed below. We will complete all necessary paperwork, file claim and negotiate with your insurance company. Memberships are effective from the month you sign up through January 2, 2020 2023 Do not send cash. Make check or money order payable to AMR (American Medical Response). PLEASE ATTACH COPIES OF BOTH THE FRONT AND BACK OF ALL YOUR PRIMARY AND SECONDARY INSURANCE CARDS. Janurary Ambu-Care APPLICATION January 3, 2019 2022 - Janurary January 2, 2020 2023 Please complete all information below and sign the Ambu-Care membership agreement. Return your completed form with your payment to AMR, Ambu-Care, 0000 X. XXX 000 Xxxxxxxx Xxxxxxxxxx,XX 00000, (000) 000-0000 Is this a Renewal or New Application? First Name Middle Initial Last Name Home Address City_ ZipCode Home Phone # Email Address @ SS # - - Date of Birth Male Female Primary Insurance Policy # Phone # Group # Insurance Company Address Supplemental Insurance Policy # Group # Supplemental Insurance Address Phone # Insured Employer Name Address Other Family Members of Household First Name Middle Initial Last Name SS # Date of Birth Male Female Primary Insurance Policy # Phone # Group # First Name Middle Initial Last Name SS # Date of Birth Male Female Primary Insurance Policy # Phone # Group # First Name Middle Initial Last Name SS # Date of Birth Male Female Primary Insurance Policy # Phone # Group # Do not send cash – make check or money order payable to AMR (American Medical Response) PLEASE ATTACH COPIES OF BOTH THE FRONT AND BACK OF ALL YOUR PRIMARY AND SECONDARY INSURANCE CARDS. All membership applicants 19 years of age or older must sign below with signature of other adult member.‌ I hereby apply for membership in the Xxxxx County Ambu-Care Membership program. I have reviewed the Ambu-Care Membership Agreement and agree to abide by the terms thereof. I request payment of authorized Medicare or other insurance benefits to me, or on my behalf, to be paid to AMR (American Medical Response), in order to determine benefits payable on my behalf, now and in the future. This agreement and authorization is executed on my own behalf and on behalf of the other members of my household, if they are minors or otherwise unable to sign. X Date X Date X Date

Limitations and Conditions. Membership benefits only extend to AMR’s advanced or basic life support ambulance services staffed with paramedics and EMT/Is, and EMTs. Membership benefits are inapplicable to services rendered by any other provider. As a condition of receiving the benefits of membership with respect to any ambulance transport, a member with insurance must comply with all coverage conditions of the applicable insurance program for such transport. Some insurance programs require the insured person to obtain prior authorization of payment for non-emergency, yet medically neces- sary ambulance services. Some plans require certain documentation from the insured with a specified time limit, or the plans deny or reduce coverage for ambulance services. In the event a member with insurance forfeits coverage by failing to comply with these types of requirements for a transport that would otherwise be covered by membership, or the services are denied as covered, then AMR shall provide the member with a 50% discount of its usual and customary charge for such transport. Non-insured household family members will receive a 50% discount for services rendered. Membership only covers ambulance services that begin in Xxxxx County and terminate in the service area(s):Xxxxx County, Arlington, Fort Worth, & Dallas hospitals. No benefits are provided for services rendered outside of these areas. I agree to pay AMR for any services it provides that are not covered by the membership benefit at 100% usual customary rates for non- medically necessary transports. AMR reserves sole discretion to deny or revoke membership and to refund membership fees (in full or in part) for reasonable cause, includ- ing but not limited to failure to comply with the terms of this Agreement. If AMR revokes my membership, I will pay all balances in full. AMR reserves the right to discontinue its membership program at any time upon notice to members. In such event, AMR shall return a pro- rated portion of the membership fee. AMR also reserves the right to unilaterally modify the terms of membership. AMR may assign its right or duties under this agreement. AMKT3-1134 If you have no insurance, or your insurance denies your medically necessary claim, AMR will bill you for 50% of the usual and customary charges. All family members, up to the age of 26 years or younger, living at your residence are covered under one membership, provided they are listed below. We will complete all necessary paperwork, file claim and negotiate with your insurance company. Memberships are effective from the month you sign up through January 2, 2020 2019 Do not send cash. Make check or money order payable to AMR (American Medical Response). PLEASE ATTACH COPIES OF BOTH THE FRONT AND BACK OF ALL YOUR PRIMARY AND SECONDARY INSURANCE CARDS. Janurary 3, 2019 2018 - Janurary 2, 2020 2019 Please complete all information below and sign the Ambu-Care membership agreement. Return your completed form with your payment to AMR, Ambu-Care, 0000 X. XXX 000 Xxxxxxxx Xxxxxxxxxx,XX 00000, (000) 000-0000 Is this a Renewal or New Application? First Name Middle Initial Last Name Home Address City_ ZipCode Home Phone # Email Address @ SS # - - Date of Birth Male Female Primary Insurance Policy # Phone # Group # Insurance Company Address Supplemental Insurance Policy # Group # Supplemental Insurance Address Phone # Insured Employer Name Address Other Family Members of Household First Name Middle Initial Last Name SS # Date of Birth Male Female Primary Insurance Policy # Phone # Group # First Name Middle Initial Last Name SS # Date of Birth Male Female Primary Insurance Policy # Phone # Group # First Name Middle Initial Last Name SS # Date of Birth Male Female Primary Insurance Policy # Phone # Group # Do not send cash – make check or money order payable to AMR (American Medical Response) PLEASE ATTACH COPIES OF BOTH THE FRONT AND BACK OF ALL YOUR PRIMARY AND SECONDARY INSURANCE CARDS. All membership applicants 19 years of age or older must sign below with signature of other adult member.‌ I hereby apply for membership in the Xxxxx County Ambu-Care Membership program. I have reviewed the Ambu-Care Membership Agreement and agree to abide by the terms thereof. I request payment of authorized Medicare or other insurance benefits to me, or on my behalf, to be paid to AMR (American Medical Response), in order to determine benefits payable on my behalf, now and in the future. This agreement and authorization is executed on my own behalf and on behalf of the other members of my household, if they are minors or otherwise unable to sign. X Date X Date X DateDate Signature of other adult member

Limitations and Conditions. Membership benefits only extend to AMR’s advanced or basic life support ambulance services staffed with paramedics and EMT/Is, and EMTs. EMT 's. Membership benefits are inapplicable to services rendered by any other provider. As a condition of receiving the benefits of membership with respect to any ambulance transport, a member with insurance must comply with all coverage conditions of the applicable insurance program for such transport. Some insurance programs require the insured person to obtain prior authorization of payment for non-emergency, yet medically neces- sary ambulance services. Some plans require certain documentation from the insured with a specified time limit, or the plans deny or reduce coverage for ambulance services. In the event a member with insurance forfeits coverage by failing to comply with these types of requirements for a transport that would otherwise be covered by membership, or the services are denied as covered, then AMR shall provide the member with a 50% discount of its usual and customary charge for such transport. Non-insured household family members will receive a 50% discount for services rendered. Membership only covers ambulance services that begin in Xxxxx Xxxxxxx County and terminate terminates in the service area(s):Xxxxx area(s):Xxxxxxx County, Arlington, Fort Worth, & Dallas hospitals. No benefits are provided for services rendered outside of these areas. I agree to pay AMR for any services it provides that are not covered by the membership benefit at 100% usual customary rates for non- medically necessary transports. AMR reserves sole discretion to deny or revoke membership and to refund membership fees (in full or in part) for reasonable cause, includ- ing but not limited to failure to comply with the terms of this Agreement. If AMR revokes my membership, I will pay all balances in full. AMR reserves the right to discontinue its membership program at any time upon notice to members. In such event, AMR shall return a pro- rated portion of the membership fee. AMR also reserves the right to unilaterally modify the terms of membership. AMR may assign its right or duties under this agreement. AMKT3-1134 If you have no insurance, or your insurance denies your medically necessary claim, AMR will bill you for 50% of the usual and customary charges. All family members, up to the age of 26 years or younger, living at your residence are covered under one membership, provided they are listed below. We will complete all necessary paperwork, file claim and negotiate with your insurance company. Memberships are effective from the month you sign up through January 2, 2020 2019 Do not send cash. Make check or money order payable to AMR (American Medical Response). PLEASE ATTACH COPIES OF BOTH THE FRONT AND BACK OF ALL YOUR PRIMARY AND SECONDARY INSURANCE CARDS. Janurary Ambu-Care APPLICATION January 3, 2019 2018 - Janurary January 2, 2020 2019 Please complete all information below and sign the Ambu-Care membership agreement. Return your completed form with your payment to AMR, Ambu-Care, 0000 X. XXX 000 Xxxxxxxx Xxxxxxxxxx,, XX 00000, (000) 000-0000 Is this a Renewal or New Application? First Name Middle Initial Last Name Home Address City_ ZipCode Home Phone # Email Address @ SS # - - Date of Birth Male Female Primary Insurance Policy # Phone # Group # Insurance Company Address Supplemental Insurance Policy # Group # Supplemental Insurance Address Phone # Insured Employer Name Address Other Family Members of Household First Name Middle Initial Last Name SS # Date of Birth Male Female Primary Insurance Policy # Phone # Group # First Name Middle Initial Last Name SS # Date of Birth Male Female Primary Insurance Policy # Phone # Group # First Name Middle Initial Last Name SS # Date of Birth Male Female Primary Insurance Policy # Phone # Group # Do not send cash – make check or money order payable to AMR (American Medical Response) PLEASE ATTACH COPIES OF BOTH THE FRONT AND BACK OF ALL YOUR PRIMARY AND SECONDARY INSURANCE CARDS. All membership applicants 19 years of age or older must sign below with signature of other adult member.‌ I hereby apply for membership in the Xxxxx Xxxxxxx County Ambu-Care Membership program. I have reviewed the Ambu-Care Membership Agreement and agree to abide by the terms thereof. I request payment of authorized Medicare or other insurance benefits to me, or on my behalf, to be paid to AMR (American Medical Response), in order to determine benefits payable on my behalf, now and in the future. This agreement and authorization is executed on my own behalf and on behalf of the other members of my household, if they are minors or otherwise unable to sign. X Date X Date X DateDate Signature of other adult member

Limitations and Conditions. Membership benefits only extend to AMR’s advanced or basic life support ambulance services staffed with paramedics and EMT/Is, and EMTsEMT's. Membership benefits are inapplicable to services rendered by any other provider. As a condition of receiving the benefits of membership with respect to any ambulance transport, a member with insurance must comply with all coverage conditions of the applicable insurance program for such transport. Some insurance programs require the insured person to obtain prior authorization of payment for non-emergency, yet medically neces- sary ambulance services. Some plans require certain documentation from the insured with a specified time limit, or the plans deny or reduce coverage for ambulance services. In the event a member with insurance forfeits coverage by failing to comply with these types of requirements for a transport that would otherwise be covered by membership, or the services are denied as covered, then AMR shall provide the member with a 50% discount of its usual and customary charge for such transport. Non-insured household family members will receive a 50% discount for services rendered. Membership only covers ambulance services that begin in Xxxxx Ellis County and terminate in the service area(s):Xxxxx area(s):Ellis County, Arlington, Fort Worth, & Dallas hospitals. No benefits are provided for services rendered outside of these areas. I agree to pay AMR for any services it provides that are not covered by the membership benefit at 100% usual customary rates for non- medically necessary transports. AMR reserves sole discretion to deny or revoke membership and to refund membership fees (in full or in part) for reasonable cause, includ- ing including but not limited to failure to comply with the terms of this Agreement. If AMR revokes my membership, I will pay all balances in full. AMR reserves the right to discontinue its membership program at any time upon notice to members. In such event, AMR shall return a pro- pro-rated portion of the membership fee. AMR also reserves the right to unilaterally modify the terms of membership. AMR may assign its right or duties under this agreement. AMKT3-1134 If you have no insurance, or your insurance denies your medically necessary claim, AMR will bill you for 50% of the usual and customary charges. All family members, up to the age of 26 years or younger, living at your residence are covered under one membership, provided they are listed below. We will complete all necessary paperwork, file claim and negotiate with your insurance company. Memberships are effective from the month you sign up through January 2, 2020 2021 Do not send cash. Make check or money order payable to AMR (American Medical Response). PLEASE ATTACH COPIES OF BOTH THE FRONT AND BACK OF ALL YOUR PRIMARY AND SECONDARY INSURANCE CARDS. Ambu-Care APPLICATION Janurary 3, 2019 2020 - Janurary 2, 2020 2021 Please complete all information below and sign the Ambu-Care membership agreement. Return your completed form with your payment to AMR, Ambu-Care, 0000 X. XXX 000 Xxxxxxxx Xxxxxxxxxx,XX 00000, (000) 000-0000 Is this a Renewal or New Application? First Name Middle Initial Last Name Home Address City_ ZipCode Home Phone # Email Address @ SS # - - Date of Birth Male Female Primary Insurance Policy # Phone # Group # Insurance Company Address Supplemental Insurance Policy # Group # Supplemental Insurance Address Phone # Insured Employer Name Address Other Family Members of Household First Name Middle Initial Last Name SS # Date of Birth Male Female Primary Insurance Policy # Phone # Group # First Name Middle Initial Last Name SS # Date of Birth Male Female Primary Insurance Policy # Phone # Group # First Name Middle Initial Last Name SS # Date of Birth Male Female Primary Insurance Policy # Phone # Group # Do not send cash – make check or money order payable to AMR (American Medical Response) PLEASE ATTACH COPIES OF BOTH THE FRONT AND BACK OF ALL YOUR PRIMARY AND SECONDARY INSURANCE CARDS. All membership applicants 19 years of age or older must sign below with signature of other adult member.‌ I hereby apply for membership in the Xxxxx Ellis County Ambu-Care Membership program. I have reviewed the Ambu-Care Membership Agreement and agree to abide by the terms thereof. I request payment of authorized Medicare or other insurance benefits to me, or on my behalf, to be paid to AMR (American Medical Response), in order to determine benefits payable on my behalf, now and in the future. This agreement and authorization is executed on my own behalf and on behalf of the other members of my household, if they are minors or otherwise unable to sign. X Date X Date X Date

Limitations and Conditions. Membership benefits only extend to AMR’s advanced or basic life support ambulance services staffed with paramedics and EMT/Is, and EMTsEMT's. Membership benefits are inapplicable to services rendered by any other provider. As a condition of receiving the benefits of membership with respect to any ambulance transport, a member with insurance must comply with all coverage conditions of the applicable insurance program for such transport. Some insurance programs require the insured person to obtain prior authorization of payment for non-emergency, yet medically neces- sary ambulance services. Some plans require certain documentation from the insured with a specified time limit, or the plans deny or reduce coverage for ambulance services. In the event a member with insurance forfeits coverage by failing to comply with these types of requirements for a transport that would otherwise be covered by membership, or the services are denied as covered, then AMR shall provide the member with a 50% discount of its usual and customary charge for such transport. Non-insured household family members will receive a 50% discount for services rendered. Membership only covers ambulance services that begin in Xxxxx County and terminate in the service area(s):Xxxxx County, Arlington, Fort Worth, & Dallas hospitals. No benefits are provided for services rendered outside of these areas. I agree to pay AMR for any services it provides that are not covered by the membership benefit at 100% usual customary rates for non- medically necessary transports. AMR reserves sole discretion to deny or revoke membership and to refund membership fees (in full or in part) for reasonable cause, includ- ing including but not limited to failure to comply with the terms of this Agreement. If AMR revokes my membership, I will pay all balances in full. AMR reserves the right to discontinue its membership program at any time upon notice to members. In such event, AMR shall return a pro- pro-rated portion of the membership fee. AMR also reserves the right to unilaterally modify the terms of membership. AMR may assign its right or duties under this agreement. AMKT3-1134 If you have no insurance, or your insurance denies your medically necessary claim, AMR will bill xxxx you for 50% of the usual and customary charges. All family members, up to the age of 26 years or younger, living at your residence are covered under one membership, provided they are listed below. We will complete all necessary paperwork, file claim and negotiate with your insurance company. Memberships are effective from the month you sign up through January 2, 2020 2022 Do not send cash. Make check or money order payable to AMR (American Medical Response). PLEASE ATTACH COPIES OF BOTH THE FRONT AND BACK OF ALL YOUR PRIMARY AND SECONDARY INSURANCE CARDS. Janurary 3, 2019 2021 - Janurary 2, 2020 2022 Please complete all information below and sign the Ambu-Care membership agreement. Return your completed form with your payment to AMR, Ambu-Care, 0000 X. XXX 000 Xxxxxxxx Xxxxxxxxxx,XX 00000, (000) 000-0000 Is this a Renewal or New Application? First Name Middle Initial Last Name Home Address City_ ZipCode Home Phone # Email Address @ SS # - - Date of Birth Male Female Primary Insurance Policy # Phone # Group # Insurance Company Address Supplemental Insurance Policy # Group # Supplemental Insurance Address Phone # Insured Employer Name Address Other Family Members of Household First Name Middle Initial Last Name SS # Date of Birth Male Female Primary Insurance Policy # Phone # Group # First Name Middle Initial Last Name SS # Date of Birth Male Female Primary Insurance Policy # Phone # Group # First Name Middle Initial Last Name SS # Date of Birth Male Female Primary Insurance Policy # Phone # Group # Do not send cash – make check or money order payable to AMR (American Medical Response) PLEASE ATTACH COPIES OF BOTH THE FRONT AND BACK OF ALL YOUR PRIMARY AND SECONDARY INSURANCE CARDS. All membership applicants 19 years of age or older must sign below with signature of other adult member.‌ I hereby apply for membership in the Xxxxx County Ambu-Care Membership program. I have reviewed the Ambu-Care Membership Agreement and agree to abide by the terms thereof. I request payment of authorized Medicare or other insurance benefits to me, or on my behalf, to be paid to AMR (American Medical Response), in order to determine benefits payable on my behalf, now and in the future. This agreement and authorization is executed on my own behalf and on behalf of the other members of my household, if they are minors or otherwise unable to sign. X Date X Date X Date

Limitations and Conditions. Membership benefits only extend to AMR’s advanced or basic life support ground ambulance services staffed with paramedics and EMT/Is, and EMTs. Membership benefits are inapplicable to services rendered by any other provider. As a condition of receiving the benefits of membership with respect to any ambulance transport, a member with insurance must comply with all coverage conditions of the applicable insurance program for such transport. Some insurance programs require the insured person to obtain prior authorization of payment for non-emergency, yet medically neces- sary medicallynecessary ambulance services. Some plans require certain documentation from the insured with a specified time limit, or the plans deny or reduce coverage for ambulance services. In the event a member with insurance forfeits coverage by failing to comply with these types of requirements for a transport that would otherwise be covered by membership, or the services are denied as covered, then AMR shall provide the member with a 50% discount of off its usual and customary charge for such transport. Non-insured household family members will receive a 50% discount for services rendered. Membership only covers ground ambulance services that begin in Xxxxx County and terminate in provided within the service area(s):Xxxxx County, Arlington, Fort Worth, & Dallas hospitalsstate of Texas. No benefits are provided for air ambulance services or services rendered outside of these areasthe State of Texas. I agree to pay AMR for any services it provides that are not covered by the membership benefit at 100% usual customary rates for non- non-medically necessary transports. AMR reserves sole discretion to deny or revoke membership and to refund membership fees (in full or in part) for reasonable cause, includ- ing including but not limited to failure to comply with the terms of this Agreement. If AMR revokes my membership, I will pay all balances in full. AMR reserves the right to discontinue its membership program at any time upon notice to members. In such event, AMR shall return a pro- rated portion of the membership fee. AMR also reserves the right to unilaterally modify the terms of membership. AMR may assign its right or duties under this agreement. AMKT3-1134 30640-I-0023 If you have no insurance, or your insurance denies your medically necessary claim, AMR will bill you for 50% of off the usual and customary charges. All family members, up to the age of 26 years or younger, living at your residence are covered under one membership, provided they are listed below. We will complete all necessary paperwork, paperwork and file claim and negotiate claims with your insurance company. Memberships are effective from the month you sign up October 1, 2018 through January 2September 30, 2020 2019 Open enrollment period is August 1st - September 30th Do not send cash. Make check or money order payable to AMR (American Medical Response). PLEASE ATTACH COPIES OF BOTH THE FRONT AND BACK OF ALL YOUR PRIMARY AND SECONDARY INSURANCE CARDS. Janurary 3READY CARE APPLICATION October 1, 2018 - September 30, 2019 - Janurary 2, 2020 Please complete all information below and sign the AmbuReady-Care membership agreement. Return your completed form with your payment to AMR, AmbuPO Box 181029, Arlington, TX 76096-Care, 0000 X. XXX 000 Xxxxxxxx Xxxxxxxxxx,XX 00000, 1029 (000) 000-0000 Is this a Renewal or New Application? First Name Middle Initial Last Name Home Address City_ ZipCode Address: Zip Code: Home Phone # Email Address @ SS # - - #: Date of Birth Birth: Male Female Primary Insurance Email: PrimaryInsurance Policy # #: Phone # #: Group # #: Insurance Company Address Address: Supplemental Insurance Policy # #: Group # #: Supplemental Insurance Address Address: Phone # #: Insured Employer Name Address Name: Address: Other Family Members of Household First Name Middle Initial Last Name SS # #: Date of Birth Birth: Male Female Primary Insurance Policy # #: Phone # #: Group # #: First Name Middle Initial Last Name SS # #: Date of Birth Birth: Male Female Primary Insurance Policy # #: Phone # #: Group # #: First Name Middle Initial Last Name SS # #: Date of Birth Birth: Male Female Primary Insurance Policy # #: Phone # #: Group # #: Do not send cash – make check or money order payable to AMR (American Medical Response) PLEASE ATTACH COPIES OF BOTH THE FRONT AND BACK OF ALL YOUR PRIMARY AND SECONDARY INSURANCE CARDS. All membership applicants 19 years of age or older must sign below with signature of other adult member.‌ member. I hereby apply for membership in the Xxxxx County AmbuArlington EMS Ready-Care Membership program. I have reviewed the AmbuReady-Care Membership Agreement and agree to abide by the terms thereof. I request payment of authorized Medicare or other insurance benefits to me, or on my behalf, to be paid to AMR (American Medical Response), in order to determine benefits payable on my behalf, now and in the future. This agreement and authorization is executed on my own behalf and on behalf of the other members of my household, if they are minors or otherwise unable to sign. X Date X Date X DateDate Signature(s) of other adult member