TEAM Application Form

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Please review and check off each statement to show you understand the program details.*

If I do not have insurance that covers ambulance service, my TEAM membership will only cover 20% of the ambulance bill, and I will be responsible for the remaining 80%.This TEAM membership covers my portion of the expense of ambulance service if provided by Adventist Health Tillamook Ambulance Services including: 1) Emergency evaluation and first aid if not transported; 2) Emergency care provided at the scene of an accident or illness; 3) Transportation to the nearest appropriate facility; 4) Medically necessary or pre-approved transports from one facility to another, including those out of our service area; and 5) Any supplies or medications used by the ambulance personnel.Services not covered include: 1) Transportation to a physician's office for routine exams; 2) Transportation home from the hospital or to a residential facility if not medically necessary to go by ambulance; or 3) Transportation to an out-of-area facility based on patient choice vs. medical need.Membership benefits will go into effect upon receipt of application and fee payment.Should you or any member of your household included on this application receive payment from a medical benefits provider for ambulance services rendered by Adventist Health Tillamook Ambulance Services, you will immediately forward payment to Adventist Health Tillamook Ambulance Services at P.O. Box 386, Tillamook, OR 97141.

Choose your T·E·A·M membership type*

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1-year membership

$60.00

2-year membership

$100.00

Lifetime membership

$1,200.00

Total

$0.00

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T·E·A·M Application

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