FEATURES
UNIQUE BENEFIT
BUSINESS SUBSCRIPTION DRIVE
2021
BENEFICIAL TO BUSINESSES & YOUR LOCAL EMS
ACT NOW
DEADLINE
EASES EXPENSE ANXIETY FOR EMPLOYEES INJURED AT THE WORK PLACE
AFFORDABLE TIERED SUBSCRIPTION BASED ON NUMBER OF EMPLOYEES
HELPS SUPPORT NONPROFIT POCONO MOUNTAIN REGIONAL EMS RAISE FUNDS TO COVER OPERATIONAL EXPENSES & ACQUIRE MEDICAL EQUIPMENT
MAY 31, 2021
SEND IN THE ATTACHED FORM WITH PAYMENT TODAY
COMMERCIAL SUBSCRIPTION MAY 31,2021-JUNE 1, 2022 EMERGENCY AMBULANCE TR ANSPORT COVER AGE FOR EMPLOYEES ONSITE
hsllc012021
2021-2022
COMMERCIAL SUBSCRIPTION EMERGENCY TRANSPORT COVERAGE FOR EMPLOYEES ONSITE
BUSINESS NAME CONTACT physical address
EMAIL PHONE
$250
Up to 10 Employees*
CHECK OFF YOUR
$500
Up to 20 Employees*
SELECTION
$750
Up to 100 Employees*
COMMERCIAL SUBSCRIPTION
$1000 Up to 200 Employees* *Limited to current employees. Subject to verification
Additional CONTRIBUTIONS AS A DONATION ARE APPRECIATED Tell us how much you’d like to pledge $ I apply for commercial subscription membership in the Subscription Program of PMREMS on behalf of the corporation/entity listed. I agree to the terms and conditions of the Subscription Program acknowledging employee emergency medical services transport is to be only from the business location indicated above. Employees utilizing this service request that payment of authorized Medicare or any other insurance benefits be made on their behalf to PMREMS for any ambulance services provided to said employee by PMREMS now, in the past, or in the future. I understand that the employee transported is financially responsible for the services and supplies provided by PMREMS, regardless of insurance coverage, and in some cases, may be responsible for an amount in addition to that which was paid by insurance. Employees participating in this program understand and agree to immediately remit to PMREMS any payments that are received directly from insurance or any source whatsoever for the services provided and assign all rights to such payments to PMREMS. Said employee(s) authorize PMREMS to appeal payment denials or other adverse decisions on their behalf without further authorization. By signing, I acknowledge that I have received PMREMS’s Notice of Privacy Practices. I am also acknowledging that I understand the text regarding the subscription program
SIGN HERE
FILL IN, print, sign & mail in your form with payment to K YOU THAN your for
N IBUTIO CONTR
POCONO MOUNTAIN REGIONAL EMERGENCY MEDICAL SERVICES 135 Tegawitha Road, Tobyhanna, PA 18466 PMREMS.org 570.839.8485 Ext. 104