POCONO MOUNTAIN REGIONAL EMERGENCY MEDICAL SERVICES 2008-2009

New __________            Renewal ____________

Tunkhannock Township  _______ Tobyhanna Township ________ Coolbaugh Township ________ Mt. Pocono Borough _________

Name (please print) _______________________________________________________________

Mailing Address:___________________________City _____________________State_____Zip _____

Residential Address (if different from above) ______________________________________________________________________

Family Subscription Rate ............................$55.00

Credit Cards Accepted M/C, VISA  Card #_________________________________Expiration Date_______/_________

Choose Appropriate Rate

Subscription Rate ________________

Donation (optional) ________________

Total Enclosed _________________

YOUR CONTRIBUTION IS TAX DEDUCTIBLE!

PMREMS ENROLLMENT FORM

Authorization:  I authorize that payment of authorized Medicare Benefits or other insurance benefits be made on my behalf for any services furnished by this health service provider or supplier.  I authorize any holder of medical information or documentation about me to release to the Health Care Financing Administration and its carrier and/or agents, as well as this health service provider, any information or documentation needed to determine these benefits or benefits payable for any service provided to me by this health service provider now or in the future.

SIGNATURE (head of household sign here) ________________________________________________________________________

Please list family members residing in your home:

Head of Household __________________________________________Spouse____________________________________________

____________________________________   ___________________________________

____________________________________   ___________________________________