Please note, if you have a Group Membership you will need to contact our office directly to proceed with your membership application.
A Mercy Flight's membership is a great way to protect you and your family. A Mercy Flight's membership has many benefits and can save you hundreds or even thousands of dollars if you ever need medical transportation. Even if you never use an emergency service, your membership ensures Mercy Flight's lifesaving efforts continue in our community for the safety of family and friends.

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First Name *
Last Name *
Middle Initial
Mailing Address
Address *
City *
State *
Zip *
Physical Address Same as mailing
Address *
City *
State *
Zip *
Primary Phone * (no spaces or dashes)
Secondary Phone
Email *
Card Type *
Card Number *
V Code *
(3 or 4 digit Card Verification Value)
Expiration *  / 
New Membership   Renewal   Gift Membership

If anyone on the application is 62 years or older, be sure to select one of the Senior plans!


Membership Duration *
Annual Combined Air & Ground
Lifetime Combined Air & Ground
First Name
Last Name
Middle Initial
Relationship
Date of Birth  /  / 
Social Security #
Gender Male  Female
    First Name
    Last Name
    Middle Initial
    Relationship
    Date of Birth  /  / 
    Social Security #
    Gender Male  Female
 Dependent 1
    First Name
    Last Name
    Middle Initial
    Relationship
    Date of Birth  /  / 
    Social Security #
    Gender Male  Female
 Dependent 2
    First Name
    Last Name
    Middle Initial
    Relationship
    Date of Birth  /  / 
    Social Security #
    Gender Male  Female
How did you hear about Mercy Flights? *
Comments
MEMBERSHIP AGREEMENT

Mercy Flights services include Ground Ambulance within the Mercy Flights Jackson County assigned service area, Fixed Wing Air Ambulance within 1000 air miles of Medford, OR in the Western United States and Helicopter Ambulance within 150 air miles of Medford, OR in Southern Oregon and Northern California. I understand that Mercy Flights is not an insurance plan, and will bill whatever insurance or medical benefits I may have and/or be entitled to for services rendered by Mercy Flights. I also understand that Mercy Flights membership fees are non-refundable and there is a 30 day waiting period for member benefits to take effect. I understand that I will be responsible for any denied, disallowed, or non-medically necessary transports, as determined by my insurance company or other third party payer. If I do not have any insurance, I will be responsible for a portion of the bill. Should I or a covered family member receive payment from insurance or other medical benefits for ambulance services rendered by Mercy Flights, I will immediately forward such payment to Mercy Flights. The Mercy Flights membership is not solicited from persons who receive Medicaid medical benefits and such membership constitutes a voluntary contribution only. I understand that violation of such terms of this agreement or substantiated abuse of ambulance services may result in cancellation.

ELIGIBILITY:
Eligible household members consist of the head of household, spouse, and immediate family members who live at the same physical location, are legal dependents (as determined by Internal Revenue Service guidelines) and are under 19 years of age.  These legal dependents can include unmarried dependent fulltime students, under the age of 22, who reside at a different physical location or a spouse who resides in a care facility.  Qualifying household members also include: disabled children, minor children of non-custodial parents, domestic partners, and dependent parents residing at the same physical location. Disabled children and dependent parents will continue their membership, if they move from the household into a care facility.

NOTICE: This Mercy Flights, Inc. Ambulance Plan is not an insurance program. Membership benefits are for services provided by Mercy Flights Inc. only. It will not compensate or reimburse another ambulance company that provides emergency transportation to you or your family. Other ambulance company transports may occur if Mercy Flights is unable to perform within a medically appropriate timeframe. This may occur, but is not limited to, a mechanical or maintenance problem or being on another call. This may also occur if the emergency location is outside of Mercy Flights’ assigned service area. If the other transporting ambulance company has a signed reciprocity agreement with Mercy Flights, that agency’s membership benefits will be applicable to the transport.


By checking the following, I agree to the above statements.
I accept    I decline
Mercy Flights Incorporated - 2020 Milligan Way - Medford, OR. 97504 - TEL: 1-800-903-9000 | Designed, Developed & Deployed by ProjectA

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