This is not an application for an insurance policy. Please read the following
before enrolling in the Humboldt General Hospital EMS Rescue
GROUNDGold Ground Transport Membership Program.
I understand that the $55 membership fee for the Humboldt General Hospital
GROUNDGold Ground Transport Membership Program covers my portion of HGH EMS Rescue’s
paramedic ambulance services that are medically necessary, and that are
applied to co-insurance or deductibles by insurance or Medicare. "Medically
necessary" is defined as a specific need for ambulance transportation
to or from a health care facility (such as a 9-1-1 emergency call, non-emergency
request, or an interfacility transfer) within HGH EMS Rescue’s primary
service area, where use of other forms of transportation, such as private
car or taxi, would be medically inappropriate. I understand that HGH EMS
Rescue can require physician certification of medical necessity. I also
understand that if abuse of the service is found to exist, my membership
may be terminated.
I understand that my
GROUNDGold membership covers those persons who permanently reside in my household
and who are included on this application. A "household" is defined
as all persons who permanently reside at the "Head of Household's"
physical address, in a senior care facility or in a nursing home.
I understand that
GROUNDGold membership is available only to legal residents of HGH EMS Rescue’s
primary service area, which includes all of Humboldt County, portions
of Lander and Pershing counties and southern Oregon.
I understand that
GROUNDGold membership does not cover the service of any type of air transport including
helicopters or fixed wing aircraft.
I understand that
GROUNDGold is not an insurance policy, nor is it meant to be a substitute for health
insurance. I agree that if I have no insurance or other health coverage,
or if my insurance company or other health benefits payer denies payment
to HGH EMS Rescue because it determines that my ambulance services were
not payable, I will be responsible for the payment of the fees for those
services. I agree to pay the fees less a 20 percent discount granted by
HGH EMS Rescue because I am a
I understand that this membership plan does not cover the service given
by other providers, including other 9-1-1 providers who provide back-up.
Medicaid patients receive full coverage for services. Therefore, there
is no reason for Medicaid patients to become
I understand that the
GROUNDGold program limits the number of transports per household membership to 10 per year.
I understand that my membership is non-transferable and non-refundable.
I understand that the effective date for my membership is the date that
HGH EMS Rescue receives my completed and signed Membership Application
and fee, and is effective for one year, until the expiration date listed
on my membership card.
ASSIGNMENT OF BENEFITS: I understand that my
GROUNDGold membership is not an insurance plan and that HGH EMS Rescue will bill
and receive payments from my insurer or third party (such as Medicare,
Blue Cross, etc.). I hereby authorize all benefits to be made directly
payable to HGH EMS Rescue. If I have Medicare, I request that payment
or authorized Medicare benefits be made on my behalf to HGH EMS Rescue
for any ambulance service provided to me by HGH EMS Rescue. If I receive
payment from Medicare or my insurance company, I will immediately forward
that payment to HGH EMS Rescue. If I do not, I understand that my membership
may be terminated and I will be billed full charges for HGH EMS Rescue
services. I acknowledge that I am responsible for payment of ambulance services.
LIFETIME SIGNATURE AUTHORIZATION: To facilitate processing, I authorize
the release to HGH EMS Rescue, the Centers for Medicare and Medicaid Services,
or other insurer of any medical information or documentation held by anyone
necessary to process a claim now or in the future, and further assign
and authorize such payments to HGH EMS Rescue. I permit a copy of this
authorization to be used in place of the original.
HGH EMS Rescue is compliant with HIPAA regulations. A copy of our Notice
of Privacy Practices is available upon request.
If you are already a member of
GROUNDGold, your renewal application will be mailed to you. If you have not received
your renewal materials call (775) 623-5222, ext. 1363.
Each household member over the age of 18 must agree to the above terms.
The insured applicant must sign and date the application showing that
he/she has read, understands and agrees to the GROUNDGold terms. Send
the completed and signed application along with your payment to: Humboldt
General Hospital, c/o HGH EMS Rescue, 118 E. Haskell Street, Winnemucca,
Nevada 89445. If you are paying by credit card, you may fax your completed
and signed application to (775) 623-8541.
Click here to download the
GroundGold Ground Transport Membership Program brochure.
Click here to enroll in the
GroundGold Ground Transport Membership Program.