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EMS Lifecare

  1. Ems Logo 2014.jpg

  2. The Shreveport Fire Department is beginning this year's EMS Lifecare Campaign. EMS Lifecare is an ambulance membership program that is offered by the Shreveport Fire Department to the public in order to help reduce the high cost of ambulance service.

    We realize that emergency ambulance service is expensive. Your membership in EMS Lifecare will cover the uninsured portion of the cost of emergency services for you, your spouse, and any other qualified dependents as determined by IRS and living at the address listed on this application. The term of the membership agreement will be from June 1st of the current year to May 31st of the following year. We urge you to take this opportunity to provide this security for you and your family.

  3. Open Enrollment: March 1 - May 31
    Please complete in full and SUBMIT

  4. Select one

  5. List spouse, children, and other dependents as determined by the IRS and living at the address listed. (First name, middle initial, and last name) All information is required for each dependent.

  6. Select one, then mail payment with copy of the form. If online option is selected the confirmation page will direct you to another site which is authorized to receive your payment.

  7. P.O. Box 54325, New Orleans, LA 70154-4325

  8. THIS IS NOT AN APPLICATION FOR AN INSURANCE POLICY

  9. I hereby apply for membership with the City of Shreveport’s Emergency Medical Service Program. I understand that the enclosed annual fee of thirty-five dollars ($35.00) will cover myself, spouse, and any other qualified dependents as determined by the IRS and living at the address listed on this application. I understand that through this membership, the City of Shreveport’s Emergency Medical Service will provide emergency ambulance service within the city limits of Shreveport. I also understand and give my permission for the City of Shreveport’s Emergency Medical Service to bill my insurance and obtain benefits which are entitled through my insurance carriers. This membership will cover the portion unreimbursed by the medical coverage for services rendered by the City of Shreveport’s Emergency Medical Service during the time of my membership.

    I authorize the release of medical information for the purpose of billing my insurance. I understand that should I or a family member receive payment from insurance or any medical provider for services rendered by the City of Shreveport’s Emergency Medical Service, the payment will be immediately forwarded to the City of Shreveport’s Emergency Medical Service to the extent necessary to satisfy any balance due.

    I do understand that the City of Shreveport’s Emergency Medical Service fees are not solicited from person(s) who receive welfare medical benefits (Medicaid) and such membership constitutes a voluntary contribution.

    I understand that the City of Shreveport’s Emergency Medical Service provides ambulance transportation in true emergency cases only and that violations of the terms of this agreement may result in immediate cancellation of my membership or other penalty. I also understand that this membership is non-refundable and non-transferable.

  10. I authorize a copy of this agreement to be used in lieu of the original. I authorize payment of insurance benefits for ambulance services for myself or family members directly to the City of Shreveport’s Emergency Medical Services according to our agreement and as itemized on the attached claims. I have paid the $35.00 membership for ambulance services to be rendered and expect your usual and customary ambulance reimbursement on my behalf to be sent directly to the City of Shreveport’s Emergency Medical Services.

    Term of Agreement: June 1st of year signed to May 31st of the following year

  11. IMPORTANT: IN LIEU OF SIGNATURE YOU MUST CHECK THE AGREEMENT BOX BELOW FOR THIS APPLICATION TO BE VALID.

  12. THANK YOU FOR YOUR SUPPORT

    For Additional Payment Information Call
    (318)841-0210

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  14. This field is not part of the form submission.


City of Shreveport, Louisiana