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Join us - Subscribe to our Fund Drive

Fund Drive Enrollment
Fund drive card number:

* required fields

Please Include your fund drive card number.

If you do not have one, leave the default of '00000.'

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Household Residents

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DOB

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Instructions
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2023 Subscription rates

Single.........................$65.00

Senior Single.............$40.00

Senior Couple...........$80.00

Family......................$110.00

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This section registers you, your family, and your donation amounts for our records.

Your donation amount is calculated based on the resident and age information shown to the left under "Membership rates".

 

For any additional contribution, click the check box for that, and then add the amount.

When finished, select the "Click to calculate your total donation" checkbox. Then confirm the amount on the right side.

Clicking "Donate Now" enters your data into our system.

Then - PLEASE! - continue to PayPal (at the bottom of this page) and follow the instructions there, the same as you do for any PayPal payment.

You will need to enter the donation amount there also.

<-- Click to calculate your total Subscription amount

Total donation:

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Re-enter your donation amount to ensure we have it correct--->

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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 Healthcare Financing Administration and its carrier agents, as well as this health service provider, any information or documentation needed to determine these benefits or benefits payable for any services provided to me by this health service provider now or in the future. I understand that I am financially responsible for the services provided to me or my family members by this health service provider or supplier regardless of my insurance coverage. I request that payment of authorized Medicare or other insurance benefits be made on my behalf to the health service provider or supplier or its billing agent for any services provided to me by the health provider or supplier.

 

I authorize and direct any holder of medical information or documentation about me to release to the Center of Medicare and Medicaid Services and its carriers and agents, as well as to this health care provider or supplier and their billing agents, any information or documentation needed to determine these benefits payable for any services provided to me by the health service provider, both now and in the future. I also agree to immediately remit to this health service provider any payments any payments that i receive directly from any source for the services provided to me, now or in the future.

Thank you for       your donation!  

                                

Please proceed    to PayPal.             

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Paypal

 

You can now make a donation through PayPal straight to Point Pleasant-Plumsteadville EMS! We are a registered non-profit organization, so your donation is 100% tax deductable! Please donate today!! 

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