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Arvada Fire Protection District 
Arvada Fire Protection District 
303-424-3012 
amanda.pollard@arvadafire.com 
 

Ambulance Membership Program

Terms of Agreement

Definitions: The Arvada Fire Protection District Ambulance Membership Program ("Program") is a voluntary ambulance membership program operated by the Arvada Fire Protection District ("District"). The program is not insurance. It is in addition to any medical benefits a Program member may have. The District will bill a program member's insurance or other coverage for ambulance services, and the District is entitled to all amounts paid by a Program member's insurance or other coverage for the District's ambulance services, up to the total dollar amount charged by the district for the services provided. 

Membership Benefits: Membership covers applicable patient out-of-pocket expenses for co-pays on medically necessary ground ambulance transportation to the nearest appropriate hospital, provided by the District within the District's ambulance service area. "Medically necessary ground ambulance transportation" means that the patient must be transported to a hospital for medically necessary services, and transportation in any other vehicle could endanger the patient's health. Medical Necessity is determined by the Center for Medicare/Medicaid Services or the patient's private insurance company. 

Membership Benefits Outside the District's Service Area: Other agencies surrounding Arvada Fire Protection District have their own ambulance membership programs. Those programs are not part of the District's Program, and no benefits to the District's Program members are guaranteed if a member utilizes another agency's transport service. This agreement does not cover: (a) emergency medical services provided for any reason by any individual or entity other than the District, including but not limited to the District's ambulance/personnel being unavailable to respond to the emergency incident, necessitating the use of mutual aid from another agency; and (b) non-emergency ambulance transportation for routine, scheduled, or non-emergency medical care. The District is not responsible for the type, level or quality of services provided by any other agency. The District is not financially responsible for any costs or charges incurred by a Program member from any other agency. 

Member Responsibilities: Program members pay an annual membership fee and will assign and transfer to the District all rights and benefits for ambulance services from all insurance policies, plans, or other benefit programs members may have, including all rights in any claim or third party recovery, up to the total dollar amount of services incurred, where the District provided ambulance services. Should any person covered under this Program receive any payment for ambulance services rendered by the District, they will immediately forward such payment to the District. Program members authorize the release of medical and other information by or to the District as necessary for ambulance billing. Program members agree to provide, when requested, any or all information concerning insurance policies, plans, third party recovery, or other benefit programs they may have, and will cooperate and assist as necessary in any efforts to bill and collect such ambulance reimbursements, including the completion and submission of documents or claim forms. 

Membership Eligibility: Residents of the District's ambulance service are eligible to join by properly completing an enrollment application available on the District website or its representatives at public events or by visiting our headquarters and by paying the appropriate annual membership fee. The Program membership may include all persons who are (a) permanent residents of the same non-commercial, single-family residence that is located within the District's ambulance service area, (b) are living together as part of a family unit, including domestic partners, but not including roomers or boarders. The first person listed on the application form is the "Primary Member." An eligible individual who joins a household after the membership goes into effect can be included in the membership up to 5 business days from the date the individual joins the household. Within the 5-day period, the Primary Member must notify the District of the addition and pay the additional fee. Only those persons who meet the membership eligibility requirements AND who are listed in the District's Program membership records at the time services are rendered are eligible for Program benefits. 

Duration: Membership coverage begins 5 business days after acceptance of a properly completed application form with payment and extends to December 31st of the year in which the member enrolls. New members may join at any time during the year and the membership fee will be prorated based on number of months left in that year. 

Responsibility for Payment and Consent to Release of Medical Information for Billing and Payment: Except as otherwise expressly provided in this agreement, the Program member is financially responsible for the emergency medical services, regardless of insurance coverage. The Program member authorizes and directs any holder of medical information or documentation about the member to release to the centers for Medicare and Medicaid Services and its carriers and agents, the District and its billing agents, and any other payers or insurers, any information/documentation needed to determine these benefits or benefits payable for the emergency medical services provided pursuant to this agreement. By signing this agreement, the Program member authorizes use of a copy of this agreement in place of the original file at the District's office and, further, directs Medicare/Medicaid and its carriers and agents, and any other payers or insurers, to remit payment on my behalf directly to the District. 

Disclaimer: The District has the right to add, modify, or delete any of the Program terms and conditions completely or in part. All interpretations of the membership terms and conditions shall be at the sole direction of the District. Membership is non-transferable and non-refundable. Violations of this agreement may result in membership revocation, forfeiture of benefits associated with membership and an obligation to pay all balances in full. 

To print the Terms of Agreement for your personal records please click HERE.