I hereby apply for an Essex Rescue subscription covering all permanent residents living within my household who are listed on this agreement. I understand that the subscription fee for the plan I selected is per household, is not prorate, and covers unlimited medically necessary pre-hospital emergency care, to me and any permanent residents listed as household members within the primary service area covered by Essex Rescue.
I understand that this agreement only applies to emergency medical services provided by *Essex Rescue between January 1, 2025 to December 31, 2025. This subscription is terminated if the subscriber provides dishonest information or moves outside Essex Rescue's primary service area. I understand that as a subscriber, Essex Rescue will bill the patient’s medical insurance for services rendered by Essex Rescue and any remaining balance not covered by insurance will be waived per the terms of this agreement.
I understand that this subscription permits Essex Rescue, Inc., to collect directly from any third-party agency whatever benefits may be available at no charge to me or my household members, and that this subscription is nonrefundable and is nontransferable. I request payment of authorized Medicare benefits and/or other insurance benefits be made on my behalf to Essex Rescue, Inc., whether in the past, present, or in the future. I authorize any holder of medical information about me or other relevant documentation about me to be released to Centers for Medicare and Medicaid Services and its agents and contractors, any and all appropriate third-party payers, whether in the past, present or in the future. I understand that any insurance payment received directly by the patient from their insurance company for services provided by Essex Rescue must be surrendered to Essex Rescue. For the terms of this subscription to be valid, I understand that Essex Rescue must have received the completed and signed 2025 subscription agreement form and full payment. Partial year subscriptions will not be prorated to remaining subscription months.
* These subscription terms also apply to Jericho & Underhill resident(s) who elect and pay for dual subscription coverage for EMS services provided by Richmond Rescue and/or Essex Rescue and live within Essex Rescue’s primary service area.
Any amount paid in addition to the selected subscription coverage fee is a donation which is greatly appreciated by Essex Rescue. Gifts and donations to Essex Rescue, a 501 (c)(3) non-profit organization, are tax deductible within the limits of federal and state laws. Essex Rescue does not provide goods or services as whole or partial consideration for any donations or gifts. Please keep the yellow copy of this form for your tax records along with your canceled check or bank statement.
