CALIFORNIA EMERGENCY AIR AMBULANCE MEMBERSHIP

MUST READ , SIGN, AND RETURN AT ANNUAL PURCHASE

Mercy Flights, Inc. is based in Medford, Oregon and provides this ambulance membership program to cover only the provision of Helicopter and Fixed Wing Air Ambulance services for emergency medical responses and transportation.  Helicopter response is limited to within 150 miles of Medford, Oregon or as regulated by NOR-CAL EMS.  PLEASE CONTACT OUR OFFICE to determine Mercy Flights’ current primary and secondary response areas.  Be aware that members should request Mercy Flights transport at the time of need, even if Mercy Flights is the secondary responder for the geographical area.  Non-emergent or not medically necessary transportation is not included or covered by this plan.  Mercy Flights membership fees are non-refundable.

Mercy Flights membership benefits apply only to services rendered by Mercy Flights for all eligible household members.  Eligible household members consist of the head of household and immediate family members, living at the same physical location, who are legal dependents (as determined by Internal Revenue Service guidelines).  These legal dependents can include unmarried students residing at a different physical location or a spouse residing in a care facility.  Qualified household members also include: minor children of non-custodial parents, domestic partners, and parents who are previously listed as part of the original household membership, but have moved into a care facility.

California memberships are set according to the KNOX KEEN HEALTH CARE SERVICE PLAN ACT AMENDMENT TO TITLE 28, SECTION 1300.43.3 AMBULANCE PLANS CONDITIONAL EXEMPTION.

California residents must read and sign the following:
BEFORE YOU PURCHASE:   If you are currently enrolled in a Health Maintenance Organization (HMO) or other health insurance, the benefits provided by an Ambulance Plan may duplicate the benefits provided by your HMO or other health insurance.  If you have a question regarding whether your  HMO or other health insurance offers benefits for ambulance services, you should contract that other company directly.

WARNING:  This Mercy Flights, Inc. Ambulance Plan is not an insurance program.  It will not compensate or reimburse another ambulance company that provides emergency transportation to you or your family.  This may occur when the 911 Emergency System has independently determined that another company could provide more expeditious service or is next in the rotation to receive a call.  This might also occur when Mercy Flights is unable to perform within a medically appropriate timeframe due to a mechanical or maintenance problem or being on another call.

By my signature I acknowledge the above stated limits to this agreement.

SIGNATURE_______________________PRINT NAME________________________DATE __________

COMPLAINTS:  For complaints regarding this Ambulance Plan, first attempt to call Mercy Flights at 1-800-903-9000.  If Mercy Flights fails to resolve the complaint to your satisfaction, contact the Department of Managed Health Care at 1-800-400-0815.  The Department’s website is http://www.dmhc.ca.gov.  You may obtain complaint forms and instructions online.

OPERATING UNDER CONDITIONAL EXEMPTION:  This Ambulance Plan is operating pursuant to an exemption from the KNOX KEEN HEALTH CARE SERVICE PLAN ACT OF 1975 ( Health and Safety Code section 1340 et seq.).

For further information, or if you have any questions please call any of our staff at 1-800-903-9000.

BTS, LLC is the FAR Part 135 Certificate Holder providing aviation services and owns and operates the helicopter used by Mercy Flights, Inc.