2008 Subscription Application
Avonmore Life Savers EMS, Inc.

(Click Here for .pdf format printable application - opens in a new window.)

Why Become A Member?

Emergency Service – Your membership entitles you and any member living in the same house, to an unlimited number of medically necessary emergency calls.

Transfer Services – Non-emergency ambulance transportation service is available. A physician's completed medical necessity authorization must be submitted prior to the transport.

Call (724) 697-5148 or (412) 955-0041 (Pager) to schedule Non-Emergency Ambulance Transportation.

Membership Benefits

1. Your membership fees are tax deductible.
2. Our membership means you NEVER have any out of pocket expenses for emergency ambulance services provided by Avonmore Life Savers EMS, Inc. We handle all billings to your insurance companies and we will accept the insurance reimbursement as full payment. Occasionally payments for ambulance services are sent to the patient rather than directly to us. If this happens, please forward the endorsed check and statements to: Avonmore Life Savers EMS, Inc., P.O. Box 246, Avonmore, PA 15618-0246.

Membership Agreement

I understand that my Avonmore Life Savers EMS, Inc. annual subscription of $50 for families, $40 for a single person, and $20 for Senior Citizens covers any deductible and / or amounts not paid by insurance for emergency services rendered by the Avonmore Life Savers EMS, Inc. during the time of the subscription. I understand that my subscription will cover myself, my spouse, and any dependants living at the same address. I also understand and give my permission for the Avonmore Life Savers EMS, Inc. to bill my insurance carriers. I understand that the Avonmore Life Savers EMS, Inc. will accept assignment of benefits from my insurance company and will bill my insurance directly for me. I understand that by billing directly, payment for my ambulance service should be sent directly to the Avonmore Life Savers EMS, Inc. I agree that should I receive payment from my insurance company for services rendered by Avonmore Life Savers EMS, Inc., I will immediately forward this payment to the Avonmore Life Savers EMS, Inc.

The current memberships will expire at midnight on January 31, 2008. Renewals will extend your membership until January 31, 2009. Membership fees are non-transferable and non-refundable.

Membership will NOT be valid unless the form is signed!

Thank you for your continued support of the Avonmore Life Savers EMS, Inc.!

Please Make Checks Payable To - Avonmore Life Savers EMS, Inc.
Please send membership form and payment to:
Avonmore Life Savers EMS, Inc.
323 Westmoreland Avenue, P.O. Box 246, Avonmore, PA 15618-0246

Additional membership forms can be downloaded at www.Saltsburg.org/AvonmoreLifeSavers/2008_Subscription_Application.pdf