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2. First Name*
3. Last Name*
5. Plan Type*
   -- Select One --Individual Plan: 1 Individual ($25)Family Plan: 1-2 Family Members ($45)Family Plan: 3+ Family Members ($75)Business Plan: 1-10 Employees ($100)Business Plan: 11-25 Employees ($150)Business Plan: 25+ Employees ($200)

   Please select a plan from the dropdown menu.

7. Additional Family Members at Residence
   List all family members living at your residence who will be covered by the plan. Please note: the number of family members listed must be consistent with the plan/level of coverage you have selected.
8. Upload Employee Roster
   Upload a current roster or list of employees who will be covered by the plan. Please note: the number of employees listed must be consistent with the plan/level of coverage you have selected.
10. Business Name (if applicable)
    Only complete if you have selected a business plan.
12. Address of Residence or Business to be Covered by Plan*
14. Address2
16. City*
17. State*
18. Zip*
20. Email Address*
21. Would you like to receive email updates about the Ambulance Subscription Plan?*

    1. Yes
    2. No
22. How did you hear about the Ambulance Subscription Plan?*

    1. Enrollment Packet Received in the Mail
    2. Facebook
    3. Email
    4. Magazine Article or News Story
    5. Family Member or Friend
    6. Other
24. Authorization*

    By clicking the “I Agree” button below, I request that payment of authorized Medicare benefits or other insurance benefits be made on my behalf to Caroline County EMS (“CCEMS”) or its billing agent, Medical Claim Aid (“MCA”) for any ambulance and emergency medical services provided to me. I authorize and direct any holder of medical information or documentation about me to release to the Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration) and its carriers and agents, as well as to CCEMS and MCA, any information or documentation needed to determine these benefits or benefits payable for any service provided to me by CCEMS, or related services provided by any other organization performing services in concert with CCEMS, now or in the future. I agree to immediately remit to CCEMS or MCA any payments that I receive directly from any insurer for services provided to me. I understand that failure to remit payment will result in bills going to a third party collection agency. I understand that I will be provided with a copy of CCEMS’s Notice of Privacy Practices at the time of service. I further certify and affirm that I am empowered to authorize the proceeding conditions for any individual covered by the plan I have purchased and that those covered individuals agree to be bound by the terms and conditions listed herein. A copy, including an electronic copy, of this form is as valid as the original.

    1. I Agree
26. After you submit this form, you will be directed to a page to process your payment.
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28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit

* indicates a required field