Apollo Medi Trans250 Cushman St., Suite 4J

Fairbanks, AK 99701

by“ARE YOU A MEMBER?

YOU SHOULD BE...”

Guardian Flight’s Membership Program

How does it work?

Guardian Flight works closely with local fire departments, ground ambulances, law enforcement agencies, medi-cal facilities, and physicians to ensure safe, expedient, and lifesaving care for our patients.

If I am traveling, am I covered?

YES! The benefit of your membership is that it will give you the flexibility that you require. When you become a member, your membership extends to all AMRG companies nation-wide. This means if you are transported by any AMRG company, you are covered by your membership at no additional cost!

What is considered a household?

A household is considered to be the primary member, a spouse/domestic partner, and any dependent under the age of 26.

If I’m a renewing member, do I have to fill out an application?

All members will be contacted with renewal information. If you were not contacted, please call our office at 888-457-1711.

In the event that you or a family member requires a medically necessary transport from one facility to another or to be transported from an emergency scene by Guardian Flight, you will not be billed for any out-of-pocket expenses associated with an air medical transport.Apollo by Guardian Flight will continue to

offer 24 hour telemedicine for assistance with emergency medical transportation. 1-877-907-4911

Why Should I Become an Apollo

MT Member?

CALL FOR MORE INFORMATION

888-457-1711

apollo medi trans

apollo medi trans

Guardian Flight Base Locations

Your membership will protect you or a family member if or when there is a need for air medical transportation by Guardian Flight.

Apollo by Guardian Flight is owned by Guardian Flight Inc. which is an air ambulance provider operating in the State of Alaska, the membership offers benefits for members transported by Guardian Flight Inc. only, and it does not cover other air ambulance providers in conjunction with Alaska State Statute 21.61.100 section c.

Membership coverage area not limited to base locations

- Within 1 hour response time

Alaska

Alaska

Valdez

BayPrudhoeBarrow

Nome

Bethel

Ketchikan

Juneau

Sitka

Dutch Harbor

Fairbanks

Anchorage

Kotzebue

Member’s Full Name: First Middle Last

Birth Date: Phone: Month Day Year

Mailing Address: Number and Street or P. O. Box # City State Zip Code

Health Insurance: Health Insurance ID #:

Provider’s Phone: Health Insurance Group #:

Family Member’s Name*: Relationship to Primary Member: Insurance Provider: Birth Date:

By enrolling in Guardian Flight Inc.’s membership program, Apollo MT, by Guardian Flight, I agree as follows:

• Membership applies to me, my spouse/domestic partner and dependent children under the age of 26 as listed on the application.

• All services covered by this membership must be arranged through or authorized by Guardian Flight Inc. (GFI) or another AMRG company and must be within GFI’s scope of care. • If I receive an air medical transport by GFI, GFI will bill my insurance or other responsible third party payer (collectively, “Insurance”). GFI will accept the amount paid by my insurance as payment in full for any medically necessary transport. The membership fee constitutes prepayment for any deductible, copayment or other out-of-pocket expense not covered by my insurance, so I will be relieved of any out of pocket expense following transport. Subject to the foregoing, I acknowledge that I am responsible for payment for ground ambulance services rendered to me. Any payment(s) sent to me by my insurance for a GFI air ambulance flight must be submitted to GFI within ten (10) days of receiving payment.• In the event I am transported by an AMRG transport program, I hereby assign and transfer to AMRG all benefits payable by Insurance to or for my benefit, or the benefit of my spouse or dependents that are named as enrollees on my membership, for any services rendered.• Membership covers only medically necessary air medical transports completed by GFI or another AMRG company, and only those transports to the closest appropriate hospital. Medical necessity will be established by the sending physician and/or the GFI Medical Director physician. Medical necessity means a condition wherein the member has been injured or suffering from an illness where a treating physician or a physician assistant has determined that the medical treatment needed is of an emergent and/or urgent nature and unavailable in the current location of the member. • The Apollo MT, by Guardian Flight program only applies to emergent transports and does not apply to any scheduled transport or non-emergent transport.• I understand that under some circumstances, GFI may not be available to transport me. This may be due to weather conditions, maintenance, aircraft previously committed to another transport, FAA restrictions, governmental market restrictions or other factors. I understand that membership does not cover the cost of any transport rendered by other air or ground providers other than GFI or another AMRG company.• Membership becomes effective three (3) days after GFI’s receipt of a completed application, accompanied by a payment of the membership fee. There is no waiting period for membership renewal. The membership application may be withdrawn or canceled during this grace period and membership fees refunded.• Neither I, nor the family members named below, are Medicaid enrollees.

• I certify that I am the individual applying for membership and am the legal representative of my spouse and dependent children listed below, and am duly authorized by them to execute this application and accept its terms and conditions on their behalf.

MEMBERSHIP TERMSIf I’m a renewing member, do I have to fill out the application?

All members will be contacted with renewal information. If you were not contacted, please call us at (888) 457-1711.

If I’m on a fixed income, is it wise for me to join this membership program?

The Apollo MT, by Guardian Flight program is ideal for anyone, especially those on a fixed income, who might otherwise have to absorb the portion of the bill not covered by insurance.

If I am transported by ground ambulance to the aircraft, will my membership cover the cost of the ground ambulance?

No, the membership program does not cover ground ambulance charges.

Is Guardian Flight guaranteed to be available when requested for transport?

Guardian Flight will make every effort to respond to requests from our members. We have flight crews and aircraft on duty and available 24 hours a day, 7 days a week. However, there are many reasons a crew may be unavailable to respond:

• Aircraft may be dedicated to a prior patient transport• Weather conditions may prevent flying in your area• You may be in a location where aircraft cannot land• You may require ground transport• You may not be in an area where a Guardian Flight aircraft is available

If I am a Medicaid recipient should I purchase this membership?

If the primary member or any dependents listed have Medicaid, please call (888) 457-1711 to process your application.

Do I have to be insured to be a member?

No, this product is for the insured and uninsured.

Can I cancel my membership?

Yes, if you move from Alaska or wish to cancel your membership, we will refund a prorated portion of your membership fee.

More questions? Call (888) 457-1711, or visit us at apollomt.com.

QUESTIONS?

Promo Code:

PLUS PROGRAM APPLICATION

1 - Year membership: $125

PAYMENT OPTIONS

Visa Mastercard American Express Check/Money Order (mail with this application)

Signature: Date:

You can also fill out an application online at www.apollomt.com

MAIL APPLICATION AND PAYMENT TO:Apollo MT by Guardian Flight ATTN: Memberships

250 Cushman St., Suite 4J, Fairbanks, AK 99701

Name as It Appears on Card (please print): Credit Card Account #: Expiration Date:

Billing Zip Code: Security Code:

Signature of Cardholder: Date:

Brochure Version 2, 2014FINAL