I hereby apply for an Essex Rescue subscription, covering all permanent residents living within my household and who are listed in this agreement. I understand that the subscription fee for the plan I selected is per household, is not prorated, and covers unlimited medically necessary emergency care, to me and any permanent resident(s) listed as household member(s) living within Essex Rescue’s primary service area. I understand that this agreement only applies to emergency medical services provided by *Essex Rescue between January 1, 2027 and December 31, 2027. 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 emergency services to be covered under the 2027 Subscription Terms, I understand that Essex Rescue must have received a completed and signed 2027 Agreement form with full payment in advance of any provided services. Partial year subscriptions will not be prorated to remaining subscription months. Essex Rescue does not provide business subscriptions. Any check received from a business will be considered a donation unless household members are listed as residents of the address listed.
* These subscription terms also apply to eligible Underhill residents living within Essex Rescue’s primary service area who elect and pay for dual subscription coverage for EMS services provided by Cambridge Rescue and Essex Rescue.
Any amount paid in addition to the subscription fee will be recorded as a donation and is greatly appreciated. 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.
