2. PLEASE NOTE: Do Not Sign Into Account
   You do not need to create an account or sign in to your account in order to renew or sign up for the Ambulance Membership Form. Instead, just fill out the form below and proceed to checkout, which will take you to PayPal's website to complete payment.
4. Primary Member Last Name*
5. Primary Member First Name*
7. Member Date of Birth*
   Member Date of Birth
8. Member ID
   Please include your membership number if you are renewing.
9. Insurance Verification*

   1. I attest that I have medical insurance.
11. Select your Membership
    Please select which membership you would like to apply for or renew. Individual memberships are for households with one resident. A family membership covers all family members who are permanent residents of the household. Senior family memberships are available to households if the primary member is over the age of 55. You will be asked to pay online via PayPal upon completing your application. Rates have been prorated accordingly.
13. Type of Membership*

    1. Individual Membership (Under 55 years old) - $13
    2. Senior Individual Membership (55 years or older) - $13
    3. Family Membership (Multiple members, all under 55 years old) - $18
    4. Senior Family Membership (2+ members of the household 55 years or older) - $15
15. Member's Street Address*
17. City*
18. State*
19. Zip Code*
20. Phone Number*
22. Name
    N/A
23. Quantity
24. Shipping Cost
25. Taxable
27. Mailing Address (if different from street address)
29. City
30. State
31. Zip Code
33. Insurance Requirement
    Everyone enrolling in the Ambulance Membership Program MUST have medical insurance (private and/or Medicare) to qualify.
35. List all family members who are permanent residents of the home and will be included in the membership.
37. Spouse Last Name
38. Spouse First Name
39. Date of Birth
    Date of Birth
40. Insurance Verification

    1. Yes, this person is insured.
42. Dependent #1 Last Name
43. Dependent #1 First Name
44. Date of Birth
    Date of Birth
45. Insurance Verification

    1. Yes, this person is insured.
47. Dependent #2 Last Name
48. Dependent #2 First Name
49. Date of Birth
    Date of Birth
50. Insurance Verification

    1. Yes, this person is insured.
52. Dependent #3 Last Name
53. Dependent #3 First Name
54. Date of Birth
    Date of Birth
55. Insurance Verification

    1. Yes, this person is insured.
57. Dependent #4 Last Name
58. Dependent #4 First Name
59. Date of Birth
    Date of Birth
60. Insurance Verification

    1. Yes, this person is insured.
62. Dependent #5 Last Name
63. Dependent #5 First Name
64. Date of Birth
    Date of Birth
65. Insurance Verification

    1. Yes, this person is insured.
67. Ambulance Membership Agreement

    THE NORTH METRO FIRE AMBULANCE MEMBERSHIP PROGRAM (AMP) will provide emergency ambulance care and transportation by North Metro Fire Rescue District within the boundaries of the District.  Ambulance transport will be provided to a nearby hospital that has the appropriate facilities for your illness or injury.  NON-EMERGENCY AMBULANCE TRANSPORTATION FOR ROUTINE, SCHEDULED, OR OTHER NON-EMERGENCY MEDICAL CARE IS NOT COVERED.  Coverage will begin upon the acceptance of the application and the payment of the annual fee.  The membership period is January 1 through December 31.  Members who enroll after January 1 will expire December 31.

    NORTH METRO FIRE AMP IS NOT AN INSURANCE POLICY AND DOES NOT FUNCTION AS A SUBSTITUTE FOR MEDICAL INSURANCE.  EACH PERSON LISTED FOR COVERAGE UNDER THE AMP MUST HAVE MEDICAL INSURANCE OR COVERAGE UNDER ANOTHER MEDICAL BENEFIT PROVIDER.  This medical insurance must include coverage for emergency transports. 

    The North Metro Fire AMP membership fee represents the pre-payment of the uninsured portion of a member’s ambulance bill up to the amount of the annual limit.  North Metro Fire Rescue District WILL BILL A MEMBER’S INSURER OR OTHER PROVIDER OF MEDICAL SERVICE PAYMENT.  A member will not be charged for costs not covered by insurance up to a maximum of $1,500 per year, per member.  In other words, the deductible and co-payment portions of an ambulance bill, usually paid by the person being transported or to whom medical services are provided, will be paid by North Metro Fire AMP on your behalf up to the limit of $1,500 per year.  Each person listed on a family membership shall be entitled to a benefit of up to $1,500 per year.  If a member receives payment from an insurance company or other medical benefit provider for ambulance service provided by North Metro Fire, the member agrees to forward the payment to North Metro Fire Rescue District.  Membership in North Metro Fire AMP is not solicited from persons who receive welfare benefits (i.e. Medicaid).

    Membership in the North Metro Fire AMP is only offered to residents of North Metro Fire Rescue District.  Membership is offered on an individual, senior individual, family, and senior family basis.  An individual membership applies to only one person.  Family and senior family memberships cover all persons who permanently reside at the address shown on the membership application (verified by Colorado Driver’s License).  Senior family memberships are available to households if the primary member is over the age of 55.  Fees are:  $40 for individual, $45 for senior family memberships and $55 for family memberships.  AMP memberships are non-refundable, non-transferable and automatically terminate if the person no longer resides in the District. 

    I hereby authorize the release of any medical information necessary to process any insurance claims and further authorize direct payment of any insurance or other medical benefits to North Metro Fire Rescue District.                     

69. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
71. Electronic Signature*
72. Date of Signature*
    Date of Signature
Leave This Blank:


73. Calculate Totals Proceed to Checkout

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