1 Year Family Membership Insurance

Please fill out the form. The information what is give helps us so that in the case of an emergency we have what we need to provide you the best care possible.

Contact Information

Insurance Information

Additional Family Members To Enroll

Family Member 2

Family Member 3

Family Member 4

Family Member 5

A copy of your insurance card(s) must be submitted with application

Just use your mouse or finger on mobile phone to sign this document.

When you click the submit and pay button you will be taken to PayPal where you can pay using a credit card or your PayPal account.

Sunrise Platinum Plan membership AGREEMENT TERMS AND CONDITIONS

  • Membership applies to myself, my spouse/partner and/or dependent children under the age of 26 who live in the home and are insured, as listed on the application.  Memberships are non-transferrable and non-refundable.
  • If I receive an air medical transport by Sunrise Air Ambulance, Sunrise Air Ambulance will bill my insurance.  The amount billed and paid must be consistent with industry standards and historical averages and will be accepted as payment for any medically necessary transport.  The membership fee is considered prepayment for any deductible,  copayment  or other out-of-pocket expense not covered by my insurance, so there will be NO out of pocket expense following the transport.     Subject to the foregoing, I acknowledge that I am responsible for payment for ground ambulance services rendered to me.
  • In the event I am transported by Sunrise Air Ambulance, I hereby assign and transfer to Sunrise Air Ambulance 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 services rendered.  Members agree to submit to Sunrise any check or payment received from insurance and responsible third parties for air medical transport, not to exceed regular charges, to Sunrise within 7 business days of receiving.
  • Membership covers ONLY medically necessary air medical transports by Sunrise Air Ambulance to the closest appropriate hospital.  Medical necessity is determined by my attending physician and approval by my insurance company.  I am responsible for the cost of any transports that are determined not to be medically necessary.  Membership will not cover charter, non emergent, elective long distance flights.
  • I understand that under some circumstances, Sunrise Air Ambulance may not be available to transport me.  This may be due to weather conditions, maintenance, commitment of the aircraft to another transport or other factors.  I understand that membership does not cover the cost of any transports rendered by air or ground providers other than Sunrise Air Ambulance.
  • I am responsible to contact Sunrise Air Ambulance at 928-537-7714of any change in my Insurance or the Insurance of any family members enrolled in Sunrise Platinum Plan.
  • This membership is not an insurance program.  It will not compensate or reimburse another ambulance company that provides transportation to  you or your family.  This may occur if sending facility determined that another company is availab;e to provide more expeditious service.  This can also occur when the ambulance plan is unable to perform within medically appropriate time frame due to mechanical or maintenance problems or being on another transport.
  • Medicare applicants must have part B coverage.  Membership starts seven (7) days after Sunrise receives payment with full application.  The waiting period will be waived in case of unforeseen events.
  • Due to constant changes in Government regulations and the insurance industry these terms and conditions are subject to change without notice, from time to time in our sole discretion.  We will notify you of amendments to these terms and conditions by posting them to our website, sunriseairambulance.com.
  • Medicaid recipients are not eligible for membership.
  • In case of insurance denial, Sunrise Air Ambulance will assist in insurance appeal process to avoid member financial responsibility.  Member shall cooperate in appeal process in a timely manner.

By clicking the Terms & Conditions button I acknowledge, understand and agree to be legally bound by all terms, conditions and notices of this agreement.  I also authorize Sunrise Air Ambulance to obtain payment as indicated by myself from PayPal, Credit Card or check.