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Waterbury Ambulance Subscription

HOUSEHOLD SUBSCRIPTION PROGRAM 2023-2024
SUBSCRIPTION IS $60.00 AND INCLUDES:

•This subscription covers you and your family from June 2023 to July 2024
• 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.

SUBSCRIBE TODAY!

Waterbury Ambulance Service is a nonprofit organization that provides prehospital emergency care to Waterbury, Waterbury Center, Duxbury and parts of Moretown 24 hours a day, seven days a week, 365 days a year, with two ambulances, more than 30 volunteers, two full-time Advanced EMT’s, as well as several Per Diem Advanced EMTs. We rely on the generosity of community members like you! Your support, volunteer work, annual household subscriptions and donations allow us to provide the community with award winning services, operations and backcountry rescue. * Our Subscription Program cost is NOT tax deductible.

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Waterbury Ambulance Subscription

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In the box below, please list all family members including yourself and their relationship to you

Household Members*

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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 $60 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 June 1, 2023 and end on July 31, 2024. 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 $60subscription 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. The $60 fee for the subscription program is not tax-deductible.

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Waterbury Ambulance Subscription

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