MEMBERSHIPPROGRAMFull Name

Address

Telephone

NAME D.O.B.RELATIONSHIP

Email

State

City

Zip Code

D.O.B.

SIGNATURE

REFERRED BY

PAYMENT METHOD

MEMBERSHIP PLANS

Credit Card Number

Card Expires Verification Number**Please enter the Credit Card Verification Number on your credit card. For MasterCard and Visa this is the last three numbers printed on the back of your card. For American Express it is a four digit number printed on the front of your card.

NEW RENEWAL

MASTERCARD VISA AMEX

CHECK CREDIT CARD

Full Name as shown on card

10888 S 300 W, SOUTH JORDAN, UT., 84095 Return Order Form to:

PLEASE MAKE CHECKS AVAILABLE TO WIREGRASS LIFE FLIGHT:

MEMBERSHIP APPLICATION

PRIMARY MEMBER INFORMATION

FAMILY MEMBER INFORMATION

1 year: $80 2 year: $120

1 year: $50 2 year: $90

3 year: $160

3 year: $130With Insurance

Without Insurance

866-290-0473CONTACT US

• I understand that my Plus Program membership is not an insurance product. I certify that I am the individual applying for membership and am the legal representative of my spouse and dependent children listed below, and am duly authorized by them to execute this application and accept its terms and conditions on their behalf.

• Neither I, nor the family members named below, are Medicaid enrollees.

• Membership covers only medically necessary air medical transports completed by Wiregrass Life Flight, or another AMRG company, and only those transports to the closest appropriate hospital. Medical necessity is determined by my insurance based on information from the attending physician. I am responsible for the cost of any transports that are determined not to be medically necessary by my insurance.

• The Wiregrass Life Flight Plus Program only applies to emergent transports and does not apply to any scheduled transport or non-emergent transport.

• Membership becomes effective three (3) days after AMRG’s receipt of a completed application, accompanied by a payment of the membership fee. There is no waiting period for membership renewal.

• I agree to notify AMRG Membership Office within five business days of any change in my Insurance or the Insurance of any family members enrolled in the Plus Program.

By becoming a member of the Plus Program, you agree to the key membership terms listed above. For a complete list of membership terms, please visit us at www.amrg.com and click “Membership.”

KEY MEMBERSHIP TERMS

www.wiregrasslifeflight.com/membershipsPROTECT WHAT MATTERS MOST!

CONFIDENT

SAFE

SECURE

• There are no out-of-pocket expenses for any emergent or medically necessary flights you or your dependents may need during the term of the agreement

• The Plus Program membership covers you and your dependents for a low annual fee

• The Plus Program provides you with coverage throughout AMRG’s extensive network (see service area map)

• The Plus Program membership provides you with peace-of-mind and reassurance that you will not be burdened by expensive air medical bills

PLUS PROGRAM BENEFITS

Wiregrass Life Flight10888 South 300 West

South Jordan, UT 84095

The need for emergent air medical transportation can happen to anyone at anytime and typically without warning. If you or a family member become ill or is involved in an accident, EMS or healthcare providers may determine that an air ambulance flight is in your best interest. Fortunately, the Wiregrass Life Flight Plus Program membership protects you, and your family from having any out-of-pocket expenses for a minimal annual fee.

Air medical transportation is expensive and health insurance may not cover all of the costs. As a member, you do not need to worry about those additional costs. We will work with your insurance provider for their portion of the bill and the rest is completely covered by your membership!

If you do not have insurance, we have a membership plan for you as well! For just $80 per year, you can also receive the same benefits described above!

“We understand that air ambulance service is a necessity and we do not take the public’s trust lightly. Wiregrass Life Flight is proud to maintain high standards in all areas of operation including protecting our patients with the Plus Program.”

With aircraft strategically located in Dothan, Wiregrass Life Flight is prepared to quickly respond to your transport needs with the highest level of care. We are capable of responding to transport requests throughout lower Alabama, southwest Georgia and the panhandle of Florida.

Wiregrass Life Flight staff are the most professional and experienced individuals in the industry. We operate state of the art, cutting edge equipment. All of which allows us to provide the best care available.

Through strategic deployment of experienced staff, fully-equipped aircraft, and management expertise, Wiregrass Life Flight crews and air-craft are on duty and available 24 hours a day, 7 days a week.

When you become a member, your membership extends to all AMRG compaines nationwide. This means if you are transported by any AMRG company, you are covered by your membership at no additional cost!

PLUS PROGRAM ADVANTAGE

EXTENSIVE COVERAGE

OUTSTANDING MEDICAL CARE

OFFSET THE HIGH COST

OF MEDICAL BILLS!

PROVIDING FINANCIAL

PEACE OF MIND.

Sincerely,

Joseph HuntPresident, AMRG

SERVICE AREA MAP- WITHIN 1 HOUR RESPONSE TIME- BASE LOCATIONS

AZ NM

COUT

MT ND

SD

MN

WIMIWY

Riverton

Gillette

Price

Ogden

Payson

Blanding

Kayenta

ChinleFort Defiance Gallup

Winslow

Window Rock

AlamosaDel Norte

Williston

Dickinson

Devils Lake

Iron MountainEscanaba

Sidney Grand Forks

Roseau

Houghton

Lander

Alaska

Deadhorse

AKHI

PR