Terms and Conditions : Wyoming

Evidence of Coverage Emergent and Non-Emergent – Wyoming

AGREEMENT FOR MEMBERSHIP: The AirMedCare Network Emergent Air Ambulance Membership Plan (“Emergent Plan”) Coverage Agreement (“Agreement”) is entered into between Guardian Fight LLC, 10888 S 300 W, South Jordan, UT 84095, REACH Air Medical Services, LLC and the individual signatory (“Primary Member”) on the Membership Plan Application (“Application”). The FLY-U-Home Non-Emergent Air Ambulance Membership Plan (“Non-Emergent Plan”) Coverage Agreement (“Agreement”) is entered into between AirMed International, 950 22nd St. N Suite 800, Birmingham, AL 35203 and the individual signatory (“Primary Member”) on the Membership Plan Application (“Application”). The Membership Office doing business as AirMedCare Network (“AMCN”) is located at 1800 Air Medical Drive, West Plains, MO 65775. AMCN can be reached by phone at 800.793.0010, Monday-Friday, 8:00am-8:00pm CST. Additional information available at www.AirMedCareNetwork.com.

By signing the Application, Primary Member agrees, on behalf of myself and the residents of my household listed on the Application, to abide by the AMCN and/or Fly-U-Home membership terms and conditions, which will commence when AMCN receives my application and payment, and will expire the following year at midnight on the last day of the month payment is received. There is a 90 day grace period for renewal applications.

PERSONS COVERED: The Plan covers Primary Member and the residents of Member’s household listed in the Application, so long as they remain full-time residents of the specified household. Dependent children who are away at school are included as long as they retain the Primary Member’s residence as their primary residence. New household members may be added, household members may be deleted, or the household location may be changed by written or verbal notice by the Member to AMCN, effective the day following receipt by AMCN of such notice. All persons covered by the Plan shall be referred to herein as “Plan Members” or “Members”. References to “I” or “me” and similar references shall be construed as including all Members.

CONDITIONS OF MEMBERSHIP: As a condition of obtaining the benefits of membership and Plan coverage, Primary Member must submit a completed, accurate Application and pay AMCN a membership fee in the amount specified in the Application.

PAYMENT FOR SERVICES: I understand that I am responsible for payment for any emergent services provided to me by Guardian Flight, REACH, or any other AMCN provider, but that my membership in the Plan will assist me by discharging that part of my financial liability that is not covered by any insurance, benefits or third party responsibility for those AMCN provider services. This membership benefit is subject to certain limitations specified in this Agreement. As a condition of receiving this membership benefit, I hereby assign to Guardian Flight and REACH all rights and benefits that I or the other Members in my household have under any and all medical, health, supplemental, worker’s compensation, liability, auto or homeowner’s insurance policies or plans or from other third party payers or sources which provide coverage or would otherwise pay for air ambulance services provided to me. Such payment sources are collectively referred to in this Agreement as “Insurance and TPL”. I authorize payment of all Insurance and TPL benefits or payments for ambulance services provided to me by Guardian Flight or REACH to Guardian Flight or REACH.

CANCELATION of SERVICES: A Wyoming resident can cancel emergent membership at any time. If canceled within 30 days of the date of this letter, the member will receive a full refund. Any request of cancelation after 30 days of this letter will result in a pro-rated refund.

EMERGENT MEMBERSHIP BENEFITS: Payment of the membership fee and compliance with the terms of this Agreement entitle Members to the following benefits within the Service Area as specified below:

1. Emergency pre-hospital air ambulance services: Members who receive medically necessary emergency air ambulance services from an AMCN provider shall pay nothing out of
2. Emergency inter-facility air ambulance services: Members who receive medically necessary emergency inter-facility air ambulance services from an AMCN provider shall pay nothing out of pocket.
3. Emergency ground services: Members who receive medically necessary emergency ground services from an AMCN provider for transports to and from an AMCN provider air ambulance, shall pay nothing out of

LIMITATIONS and EXCLUSIONS: Membership benefits extend to medically necessary emergency rotary wing (helicopter) and fixed wing (airplane) air ambulance services provided by an AMCN provider in the Service Area as described below. Membership benefits are provided for an AMCN provider emergency ground ambulance services, if provided as a means of facilitating their air ambulance services. Membership benefits will also extend to AMCN providers in the AMCN Service Area described below. AMCN providers shall apply the medical necessity standard of the Medicare program. Medicaid participants are not eligible for membership.

Guardian Flight/REACH Wyoming SERVICE AREA: The service area for Guardian Flight/REACH includes the following counties in Wyoming: Albany, Big Horn, Carbon, Campbell, Converse, Crook, Freemont, Goshen, Hot Springs, Johnson, Laramie, Lincoln, Natrona, Niobrara, Park, Platte, Sheridan, Sublette, Sweetwater, Teton, Uinta, Washakie and Weston

AMCN SERVICE AREA: The service area for other AMCN providers includes parts of the following states: Alabama, Alaska, Arizona, Arkansas, California, Colorado, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia and Wyoming.

SERVICE AREA IMPORTANT INFORMATION: In an emergency and if the member is outside of the air ambulance membership organization’s service area, air ambulance services may be provided by another air ambulance provider or air ambulance membership organization, and the benefits of this air ambulance membership organization will not apply to the services provided by another air ambulance provider.

WYOMING MUNCIPALITY COVERAGE: Members may be covered by an emergent air ambulance membership organization under a membership provided by a governmental entity. In Wyoming, the following municipalities have a membership plan: Washakie County, WY and Upper Wind River Valley Ambulance Association.

NON-EMERGENT MEMBERSHIP BENEFITS:

Air Medical Repatriation. If (1) a member, while traveling more than 150 miles from the member’s residence, is admitted to a hospital anywhere in the world that is more than 150 miles from the member’s residence in the United States or, in AirMed’s sole discretion, Canada, and (2) it is determined by the member’s physician and AirMed’s medical director that the member’s medical condition is stable enough to allow air transport but that medical escort is required, then, at the member’s request, AirMed will provide the member with private air medical transport or, if appropriate, commercial airline transport with medical escort. In either case, transport will be provided on a bedside-to-bedside basis to a hospital of member’s choice that has accepted the member as a patient, is in the United States or Canada and is more than 150 miles from the original hospital (or to member’s residence, as applicable), subject to the membership terms and conditions. If space is available and patient care is not compromised, family members, business associates, and/or traveling companions may accompany the member, at no additional cost, on AirMed aircraft during transport. References to “United States” means the 50 United States and Puerto Rico, but no other United States territories or possessions.

Transport of Mortal Remains. If a member dies while traveling more than 150 miles from the member’s residence, at the request of the member’s family, AirMed will arrange for the return of the member’s mortal remains to a funeral facility in the city of the member’s residence.

NON-EMERGENT MEMBERSHIP SERVICE AREA:

Locations Inaccessible by Fixed Wing Aircraft. Both the originating and receiving hospital must be reasonably accessible by ground ambulance to transport the member to and from an airfield capable of accommodating an AirMed or one of its authorized affiliates aircraft. The cost associated with transportation from ships, isolated areas or islands to an airport accessible to AirMed aircraft is not included in the membership benefits and will be the responsibility of the member. Membership benefits do not include helicopter transportation.

High Risk / Safety Travel Restrictions. Due to the high risk of sending U.S. registered aircraft and personnel into countries or geographic regions where the U.S. State Department, Department of Transportation, or the Federal Aviation Administration (FAA) has issued travel restrictions, membership services are not available in these areas.

High Risk / Safety Medical Restrictions. In regard to the safety of our pilots and medical crew onboard AirMed transport flights, in conjunction with FAA regulatory standards regarding airborne pathogens and flight crew’s ability to perform required emergency procedures, and in compliance with restrictions imposed by the U.S. State Department or others, a member will not be entitled to air medical transport benefits if the member’s illness or injury is a result of or is contributed to by the following: (i) suicide or attempted suicide or intentional self-injury; (ii)a member’s own criminal or felonious act; (iii) actions taken while the member is in a state of insanity; (iv) war, invasion, civil war or terrorism; or (v) contagious airborne pathogens; provided, however, that the foregoing limitations shall not apply to Members with the COVID-19 virus. A member suffering from a psychiatric or mental disorder that is not manageable and will not allow safe transport within the confines of the ground ambulance and aircraft may not be transported. A member beyond the second trimester of pregnancy may not be transported if the transport request relates to the pregnancy.

TERMINATION AND RENEWAL OF COVERAGE: AMCN may terminate the Agreement and the participation of any Members in the Plans for failure to comply with the terms of this Agreement. Any Service Area may be changed at any time without notice. AMCN reserves the right to discontinue emergent or non-emergent Plans at any time upon notice to Members. In such event, AMCN shall return a pro rata portion of the membership fee. AMCN also reserves the right to unilaterally modify the terms of these Plans, including but not limited to the membership fee charged to Members who join or renew their membership after the effective date of such change. Subject to foregoing, AMCN shall renew membership on an annual basis upon completion by a Member of an Application or renewal Application and payment of the applicable Membership Fee. Renewal contracts may include changes in coverage. Please visit www.airmedcarenetwork.com for more information or to view the full terms and conditions of membership.

IMPORTANT INFORMATION: The emergent and non-emergent membership programs are not insurance coverage. If eligible and covered under Medicare, the member may already be covered for emergent air ambulance services and should consult with a representative of the Medicare program to determine what services may be available under Medicare.

MEMBERSHIP RATES AND TERMS: Membership rates and terms are provided below. Members will be notified of any changes to the rates and terms available in Wyoming.

Discounted rates available through business plans.