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  1. *Required information. Please list the last four-digits of your Social Security Number for verification purposes.

    List spouse, children under 26, and other dependents listed on your tax return and regularly living at home. 

    (First name, middle initial, last name if different than member:)

  2. Member Insurance Information
  3. Spouse Insurance Information
  4. Other Dependents Insurance Information
  5. Payment Options
  6. Credit Card Information (American Express Not Accepted)
  7. AGREEMENT - THIS IS NOT AN APPLICATION FOR AN INSURANCE POLICY

    I hereby apply for membership with the Odessa Fire Rescue Emergency Medical Services Program. I understand that the enclosed annual fee of sixty-nine dollars ($69.00) (or $7.00 monthly) will cover myself, spouse, unmarried children under 26 years of age, and any other qualified dependents as determined by the IRS and who may live at this address. I understand that through this membership, Odessa Fire Rescue Emergency Medical Services will provide emergency ambulance service within Ector County through Odessa Fire Rescue. I also understand and give my permission for Odessa Fire Rescue Emergency Medical Services to bill my insurance and to obtain benefits, which are entitled through my insurance carriers. This membership will cover the portion unreimbursed by my medical coverage for services rendered by Odessa Fire Rescue Emergency Medical Services during the time of my membership. If a person does not have health care insurance, this program covers emergency medical services delivered prior to hospital arrival.

    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 other medical provider for services rendered by Odessa Fire Rescue Emergency Medical Services, the payment will be immediately forwarded to Odessa Fire Rescue Emergency Medical Services to the extent necessary to satisfy any balance due. 

    I do understand that Odessa Fire Rescue Emergency Medical Services memberships are not solicited from persons who receive welfare medical benefits (Medicaid) and such memberships constitutes a voluntary contribution. I understand and agree that the EMS Service to be provided under this agreement is for a governmental service and the liability of the city, its employees and officials is to be governed solely by the Texas Tort Claims Act, Chapter 101, Texas Government Code. This agreement does not constitute a waiver or modification of such laws. 

    I understand Odessa Fire Rescue Emergency Medical Services provides ambulance transportation in true emergency cases only and not for transfer ambulance service. 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. 

    To The Insurance Company 

    I authorize a copy of this agreement to be used in lieu of the original on file at Odessa Fire Rescue Emergency Medical Services office. The original may be furnished on request. I authorize payment of insurance benefits for ambulance service for myself or family members directly to Odessa Fire Rescue Emergency Medical Services according to our agreement and as itemized on the attached claims. I have paid the co-payment for ambulance services to be rendered and expect our usual and customary ambulance reimbursement on my behalf to be sent to Odessa Fire Rescue Emergency Medical Services.

  8. IMPORTANT : Must be signed to be valid
  9. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

  10. For Additional Information, Call 432-257-0502
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  12. This field is not part of the form submission.