Medical Transport Association Membership Agreement

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1 USA MEMBERSHIP AGREEMENT With payment of the membership fee, the Apollo Medical Transport Association (MTA) agrees to arrange, facilitate, and pay for urgent medically necessary air and ground transportation to the Member, along with other services listed below. These services are provided during the term listed, subject to conditions and limitations listed. If the Member has an insurance plan that covers a portion of the provided service, that plan will be billed first, and the Apollo MTA will be responsible for the balance. THIS IS NOT AN INSURANCE POLICY. IT IS A MEMBERSHIP ASSOCIATION MEMBER SERVICES 1. Urgent/Emergent Rotorwing (helicopter) air transportation. The Apollo MTA agrees to cover urgent/emergent medical transport for serious injury or illness to the nearest appropriate facility. This service is provided in all 50 states. Preapproval is not necessary for scene transports to the hospital, but is required for interfacility transports to a necessary higher level of care. 2. Urgent/Emergent Fixed Wing air transportation The Apollo MTA agrees to cover urgent/emergent fixed wing air transportation for serious illness/injury needs that require a higher level of care in all 50 states. Urgent/Emergent flights that are not interfacility transports do not require preapproval. All others require Apollo MTA physician approval which is available in real time. 3. Ground Ambulance transportation The Apollo MTA agrees to cover Urgent/Emergent transportation from home or scene to the nearest appropriate Emergency facility in all 50 states. This does not require pre-approval. Interfacility transports require Apollo MTA physician approval which is available in real time. 250 Cushman St., Suite 4J, Fairbanks, AK Page 1 of 5

2 4. Repatriation If the Member is hospitalized more than 100 miles from his/her primary home, the hospitalization is anticipated to be more than 5 days, and it is medically feasible to transport, the Apollo MTA will cover air transport to the Member to the nearest appropriate hospital to the Member s home. 5. Escort transport If the Member requires Urgent/Emergent air transport, the Apollo MTA will provide transport to a spouse or family member or companion on the flight if a seat is available. If not, the Apollo MTA will cover commercial transport to the closest available airport to the destination of the patient as available by common commercial carrier. 6. Return transportation The Apollo MTA agrees to cover transportation to the Member and spouse or family member or companion by scheduled common carrier to the commercial airport nearest the Member s primary residence following inpatient medical facility confinement as available by common commercial carrier. 7. Family/Companion transport If a Member is hospitalized for more than 5 days and is more than 100 miles from his/her primary home and does not have a family member or companion in attendance, the Apollo MTA will cover common carrier transport for that person chosen by the Member to attend. Transport will be provided from the nearest commercial airport to the primary residence to the closest commercial airport nearest the confinement as available by common commercial carrier. 8. Return of Remains If the Member dies more than 100 miles from his/her primary home, the Apollo MTA will cover transport of the mortal remains to the closest commercial airport to the Member s primary home. 250 Cushman St., Suite 4J, Fairbanks, AK Page 2 of 5

3 9. Minor children/grandchildren If the hospitalization of a Member results in minor children or minor grandchildren being unattended and there is no family member or acceptable companion present, the Apollo MTA will cover commercial air transport including a qualified attendant (if age or child condition necessitates) to the commercial airport nearest the primary residence of the Member as available by common commercial carrier. 10. Vehicle Return The Apollo MTA will provide vehicle return service for owned or rented ground vehicles following Urgent/Emergent air medical transport and the inability of the Member to drive the vehicle for 15 days or more after the illness/injury requiring transport. This applies to all 50 states. In Hawaii this only applies to rental vehicles. The Member is financially responsible for any repairs needed enroute, and the Apollo MTA will provide the driver, fuel, oil and incidental expenses. The vehicle must be in a safe and legal condition. The vehicle will be returned to the Member s primary residence unless the Member specifies a closer destination. 11. International Services When the Membership fee is paid, the above services are included in all 50 states. This membership does not cover transports outside of the 50 United States. Services are excluded where conditions are unsafe to arrange transport or other offered Apollo MTA services. 250 Cushman St., Suite 4J, Fairbanks, AK Page 3 of 5

4 EXCLUSIONS Membership services are not provided for injury or illness related to or caused by: 1. Injury or illness associated with committing a felonious act or illegal occupation 2. Mental illness or its treatment, suicide attempt/intentional self-inflicted injury 3. Illness or injury associated with active military duties 4. Elective treatment/procedures or cosmetic surgery 5. Normal pregnancy or routine pregnancy issues 6. Transports or services relating to pre-existing disease until the 30 day waiting period is completed 7. Air or ground transport that cannot be performed because of weather, restrictions, unsafe environment, or conditions beyond the control of the Apollo MTA 8. Civil disorder or act of war. 9. More than 5 ground transports in a Membership year, or more than 3 air transports PROVISIONS 1. Return of Membership fees if requested by Member within the first 15 days of Membership if no services have been utilized. After 15 days there is no return of membership fees. 2. Services #4 thru #10 must be utilized within 30 days of the transport event. 3. Pre-approval. Emergency events from home or scene do not need pre-approval for air or ground transport. Interfacility transports must be pre-approved by the Apollo MTA physician. There is a 24/7 number and access to a physician in real time for this purpose. No delays in transports are incurred. 4. Member Contract. The Member is not authorized to incur expense for the Apollo MTA. The Apollo MTA is not obligated for any Member authorized services. 250 Cushman St., Suite 4J, Fairbanks, AK Page 4 of 5

5 5. The Apollo MTA does not personally operate any air, ground or commercial air service. Apollo MTA works with quality providers worldwide to fulfill the Member obligations. 6. Record Authorization. The Member authorizes caregivers or related facilities to provide medical records to the Apollo MTA in conjunction with Member services to help facilitate care and transport decisions, and Member services. 7. The Member will be given an ID card. For those services requiring pre-approval, it is the Member s responsibility to notify facilities and caregivers of the pre-approval requirement. The Member should verify with the sending facility or caregiver that approval has been given by the Apollo MTA. 8. The membership starts 5 business days after funds received and application approved. 9. Scene (911 transports) will be covered at the billed charge or the regional usual and customary rate, whichever is lower. 10. Claims and/or proof of loss must be submitted with 120 days from the date of loss. Claims submitted past this time will not be considered for payment. DEFINITIONS 1. Air ambulance or Air Medical Service is a certified medical and air service with qualified medical personnel, appropriate equipment, and a medical director. 2. Receiving Facility is a licensed acute care hospital with 24 hour care. Rehabilitation and nursing centers are not included in this. 3. A Member is in good standing if the application and fees have been accepted by the Apollo MTA. If a family membership has been applied for, fees paid and accepted by the Apollo MTA, the spouse or domestic partner, unmarried dependent children up to age 26, and grandchildren who are in the custody of the Member are considered Members. 4. This is a travel association with prepaid member benefits. There are no voting rights, and association members cannot change the benefits or incur expense for the association except as listed in the benefits section. 5. Referral of a new association member that becomes a member in good standing will give a $25 credit on renewal of membership. 250 Cushman St., Suite 4J, Fairbanks, AK Page 5 of 5

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