SUBSCRIPTION MEMBERSHIP APPLICATION

* Required Field

$75.00 Family Membership    $55.00 Single Membership
Your donation is greatly appreciated!

Primary Member


Secondary Member


Dependent 1


Dependent 2


Dependent 3


Contact Information

Payment Options

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Release of Payment Authorization
Cetronia Ambulance Corps reserves the right to any available third party billing. Co-insurance and deductible collections are made as required by your insurance. I request that payment of authorized Medicare, Medicaid or other insurance benefits be made payable directly to Cetronia Ambulance Corps on my behalf for any service(s) provided or supplied. I authorize any holder of hospital or medical information about me, or my family members, be released to the Centers for Medicare & Medicaid Services (CMD), its agents or carriers, as well as Cetronia Ambulance Corps. This information or documentation is to be utilized strictly for the purposes of determining the benefits payable for related services.

Membership fees are NOT tax deductible. Donations ARE tax deductible.
THANK YOU FOR YOUR CONTINUED SUPPORT!
Memberships are valid for one year from date submitted