HEAD OF HOUSEHOLD
LAST NAME:
  		FIRST:
  		MIDDLE:
  		SSN:(000-00-0000)
 
PRESENT ADDRESS - STREET & NUMBER:
  		CITY:
  		STATE:
  		ZIP:
 
EMAIL ADRESS:
  		TELEPHONE:
  		BUSINESS PHONE:
  		BIRTHDATE:(MM/DD/YYYY)
 
BLUE CROSS/BLUE SHIELD NUMBER:
  		MEDICARE NUMBER:
 
SPOUSE INFORMATION
LAST NAME:
  		FIRST:
  		MIDDLE:
  		SSN:(000-00-0000)
 
MEDICARE NUMBER:
  		BIRTHDATE:(MM/DD/YYYY)
 
HOUSEHOLD MEMBERS INFORMATION (1)
LAST NAME:
  		FIRST:
  		MIDDLE:
  		SSN:(000-00-0000)
 
INSURANCE COMPANY (IF OTHER):
  		CARRIED THROUGH (E.G., EMPLOYER,UNION):
 
INSURANCE COMPANY ADDRESS:
  		CITY:
  		STATE:
  		ZIP:
 
ID NUMBER:
  		GROUP NUMBER:
 
RELATION TO HEAD OF HOUSEHOLD:
  		TELEPHONE:
  		BIRTHDATE:(MM/DD/YYYY)
 
HOUSEHOLD MEMBERS INFORMATION (2)
LAST NAME:
  		FIRST:
  		MIDDLE:
  		SSN:(000-00-0000)
 
INSURANCE COMPANY (IF OTHER):
  		CARRIED THROUGH (E.G., EMPLOYER,UNION):
 
INSURANCE COMPANY ADDRESS:
  		CITY:
  		STATE:
 		ZIP:
 
ID NUMBER:
  		GROUP NUMBER:
 
RELATION TO HEAD OF HOUSEHOLD:
  		TELEPHONE:
  		BIRTHDATE:(MM/DD/YYYY)
 
ADDITIONAL INFORMATION
   
INSURANCE INFORMATION FOR HEAD OF HOUSEHOLD / SPOUSE
INSURANCE COMPANY:
  		CARRIED THROUGH (E.G., EMPLOYER,UNION):
 
INSURANCE IS DECLARED IN:
  		GROUP NUMBER:
 
INSURANCE COMPANY ADDRESS:
  		CITY:
  		STATE:
  		ZIP:
 
TELEPHONE:
  		IS FAMILY COVERED:
   YES  NO 		IS SPOUSE COVERED:
   YES  NO
PAYMENT OPTIONS
CHOOSE ONE OF THE FOLLOWING:
  		METHOD OF PAYMENT:
 
NAME ON CARD:
  		CREDIT CARD NUMBER:
  		EXPIRATION DATE:
  /
AFFIDAVIT

I hereby apply for a MAST Family Membership for myself and my household, which includes spouse/domestic partner, parents, children, grandchildren, or siblings of mine or my spouse/domestic partner living in my residence or in a nursing home.

I understand that:
Membership covers MEDICALLY NECESSARY emergency and non-emergency MAST Ambulance trips to or from hospitals originating in Kansas City, MO; Avondale; Farley; Ferrelview; Houston Lake; Lake Waukomis; Northmoor; Oaks; Oakview; Oakwood; Oakwood Park; Parkville; Platte Woods; Riverside; South Platte County; and Weatherby Lake, and MEDICALLY NECESSARY non-emergency ambulance trips originating in Gladstone; Grandview; Johnson County, KS; and North Kansas City. Membership does not cover mileage beginning with the 50th mile and does not cover trips for patients who can walk, sit in a wheelchair or be transported by private car or taxi.

A physician certification statement (PCS) documenting the MEDICAL CONDITION that makes ambulance transportation a MEDICAL necessity is required for ALL non-emergency trips and may be required on emergency trips that are denied by Medicare or other third-party agency. Pre-authorization must be secured prior to non-emergency transports for those patients whose insurance requires such authorization. The membership fee is non-refundable, and membership is non-transferable.

MAST Membership is not insurance and membership permits MAST to collect directly from any third-party agency (Medicare, private insurance, etc.) whatever benefits may be available. Members and their household members are legally responsible to pay for MAST’s services, but for covered services MAST will accept any available third-party benefits as payment in full. Emergency transports are fully covered. An “emergency” is an unforeseen medical condition which requires urgent and unscheduled medical attention. Non-emergency transports are fully covered if insurance or other third-party coverage provides benefits for the transport. If no insurance or other third-party coverage is available or benefits are denied by the insurance company or other third-party payer, MAST members are charged a reduced fee (70% of the standard non-emergency fee).

Authorization & Consent:
I hereby assign to MAST all rights and benefits of mine and of my dependents for ambulance services provided by all third-party agencies. I further authorize all third-party agencies to pay directly to MAST whatever benefits may be available for services rendered to me or to my dependents by MAST; and I agree to help MAST collect theses benefits. If I receive a payment directly from any third-party agency, I will immediately forward the payment to MAST. If I fail to do this, I understand my membership can be terminated and regular charges for all services will be immediately due and payable from me.

I hereby authorize any holder of any medical, hospital, or other records of information about me or my dependents to release to the Center for Medicare Services, its intermediaries or other carriers, as well as to MAST, any information needed to determine third-party benefits payable for any services provided to me or my dependents by MAST now or in the future.