Departments: Ambulance Aid

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2009 Ambulance Aid enrollment form

All Forms are in PDF Format - Adobe Acrobat Reader is Required to View Forms

Ambulance Aid is a way to protect you and your loved ones from the unexpected costs of emergency ambulance transports. The current cost of an ambulance transport in Dinwiddie County can range from $385 for BLS service to $575.00 for ALS services plus $8.25 per transported mile. These costs may be covered by your healthcare plan or Medicare, however many times there can be significant deductibles or the transport can be denied payment by the insurance provider. If this occurs or you are uninsured this can leave you with substantial bills from the emergency transport. Ambulance Aid offers you protection from those costs. It will cover you and any other household member for emergency transportation to the hospital for just $29 for single household member and $59 for a Family. The plan will protect you from January 1, 2007 thru December 31, 2007.

AT NO TIME WILL YOU BE DENIED EMERGENCY MEDICAL SERVICES OR TRANSPORT BASED ON INSURANCE STATUS OR ABILITY TO PAY.

Annual membership in Ambulance Aid is just $29 for a single household member and $59 for a Family. This means that Ambulance Aid could more than pay for itself in one trip alone. Emergency Medical Services will be provided to all citizens, regardless of their financial circumstances. If an ambulance responds but the patient is not transported, there will be no charge.

Ambulance Aid covers you and any other household member(s) for emergency transportation to the hospital. The plan is available to all residents of Dinwiddie County and the family members who live in the resident�s household and, to individuals that work in Dinwiddie County. Only those household members listed on the form will be covered under the plan.

By joining Ambulance Aid, you get the same high-quality ambulance service offered to everyone who lives in Dinwiddie County. Your membership in Ambulance Aid simply protects you from high costs associated with state-of-the art ambulance care.

Ambulance Aid will cover emergency medical transport from anywhere in Dinwiddie County and covers transport to the nearest hospital, not the hospital of choice.

Remember always call 911 in an emergency, regardless of your billing concerns. Our first priority is your health and safety, not cost recovery.

Each ambulance is equipped with sophisticated lifesaving technology that�s critical during an emergency. And at least one member on duty on any given day is trained in Advanced Life Support (ALS).

To join Ambulance Aid, you must complete the enclosed application and enrollment contract form and return it to us with a check, money order or authorization to charge your Visa or MasterCard account for $29 for a single member household and $59 for a family. As soon as we receive your signed application and payment, you will be automatically enrolled in Ambulance Aid.

Coverage will begin from the date your signed contract and payment is received and continue through the end of the calendar year.

The following are the terms of the Ambulance Aid Membership Plan (the �Plan�)

1. The Plan is available to all residents of Dinwiddie County and the family members who live in the resident�s household (provided that they are enrolled in the Plan at time of application) and to individuals who work in the County.

2. The Plan covers medically necessary, as defined in the health plan, ambulance transport services to the hospital provided by Dinwiddie County. �Transports from the hospital are not included in this plan�.

3. I further understand that Dinwiddie County does not provide non-emergency transportation or wheelchair transportation.

4. The Plan only pays for the costs not covered by a health plan; Dinwiddie County will submit a claim, for payment to the health plan for each ambulance transport.

5. Plan members agree to assist the County in collecting payments from the health plan, to promptly provide necessary information and signatures for the submission of claims to the health plans, and do any other things which may be reasonably necessary to help Dinwiddie County collect payment.

6. If the Plan member receives a payment for the ambulance transport directly from the health plan, the member will immediately forward such payment to Dinwiddie County. The failure to remit this payment to Dinwiddie County within five days of receipt will result in the full cost of the ambulance transport being borne by the Plan member.

7. The Plan membership will be effective every January 1 through December 31 upon receipt of full payment and a signed membership contract.

8. The membership fee is non-refundable and non-transferable.

9. I, the undersigned, request that payment of authorized benefits be made on my behalf to: Treasurer, County of Dinwiddie, PO Box 371, Dinwiddie, Virginia 23841 for any ambulance services provided to my by Dinwiddie County.

10. I authorize any holder of medical information or documentation about me to release any information or documentation needed to determine these benefits or benefits payable for related services provided to me by Dinwiddie County now or in the future.

For more information contact:

Dinwiddie Public Safety
23910 Courthouse Road
PO Box 371
Dinwiddie, VA 23841
(804) 469-5388 Phone
(804) 469-7663 Fax

Ambulance Aid is a pre-paid service program offered by the County of Dinwiddie.
At no time will you be denied emergency medical services or transport based on insurance status or ability to pay.