2021 PMREMS Corporate Subscription Signup

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

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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