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Waterbury Ambulance Subscription

SUBSCRIPTION PROGRAM 2022-2023
SUBSCRIPTION IS $55.00 AND INCLUDES:
• Up to three emergency transports to the nearest appropriate medical facility for all subscribed household members.
• Billing & collection of benefits available from the subscribers’ medical insurance on behalf of the subscriber.
• Subscribers will not be billed for any portion of our fees (deductibles/copayments) not covered by their insurance.
• A subscription is not necessary for recipients of Medicaid.

Waterbury Ambulance Service, recently awarded “2021 Ambulance Service of the Year” for the State of Vermont, is celebrating its 50th Anniversary of providing Emergency Medical Services to Waterbury and the surrounding communities of Duxbury & Moretown. Waterbury Ambulance provides coverage 24 hours a day, 7 days a week, 365 days a year, with two ambulances, more than 30 volunteers, two full-time Advanced EMTs,
as well as several paid Advanced EMTs. It is important to note that we are a nonprofit organization not a town or state agency and we rely on the generosity of community members like you. Your support, volunteer work,
our annual family subscription, and donations allow us to provide award winning services, operations, and backcountry rescue.

This year we are in the process of planning to build a desperately needed new facility to better meet the needs of our community. A part of your donation will help to fund this project which will help us to improve our
quality & services for you.

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Waterbury Ambulance Subscription

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In the box below, please list all family members including yourself, their relationship to you, their insurance company, group number and policy number

For Example:
John Smith, Self, Green Mountain Care, Group #: 123456 Policy Number: SAN1234567
Jane Smith, Wife, Green Mountain Care, Group #: 123456 Policy Number: SAN123321
Molly Smith, Child, Dr. Dinosaur, Group #: N/A Policy #: 1234567

Household Member Insurance Plan Information*

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Payment Details

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Bank Account*

Name on Account*

Bank Routing Number*

Bank Account Number*

Card Number*

Security Code*

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Expiration Year*

Name on Card*

First Name*

Last Name*

Address, line 1*

City*

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Zip Code*

Email Address*

Phone

By submitting this form I understand I am signing up for a Waterbury Ambulance Service, Inc. Subscription covering all people living within my house. I understand that the $55 per household is not prorated and provides unlimited pre-hospital emergency care, when medically necessary, to me and my listed household members within the primary service area covered by Waterbury Ambulance Service, Inc. The subscription will begin on July 1, 2022 and end on June 30, 2023. This subscription is terminated if the subscriber moves outside Waterbury Ambulance Service, Inc.'s primary service area. I understand that if any member of my household uses services of Waterbury Ambulance Service, Inc., a bill will be sent to my insurance company and that I will not be responsible for a co-payment or deductible. Any payment I receive directly from my insurance company must be forwarded to Waterbury Ambulance Service, Inc. This subscription is non-refundable and non-transferable. I authorize payment of medical benefits to Waterbury Ambulance Service, Inc. Any amount paid in addition to the $55 subscription fee is a donation which is greatly appreciated by Waterbury Ambulance Service, Inc. Gifts and donations to Waterbury Ambulance Service, Inc., a 501 (c)(3) non-profit organization, are tax deductible within the limits of federal and state laws. Waterbury Ambulance Service, Inc. does not provide goods or services as whole or partial consideration for any donations or gifts. Please keep a copy of this form for your tax records along with your canceled check or bank statement.

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Waterbury Ambulance Subscription

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