Home :

Online Membership Application

You can now join or renew your membership to the St. Marys Ambulance Service online using your American Express, Discover, MasterCard or Visa credit card. You may also transfer funds from your PayPal account.

Simply complete the form below and then click the Submit Information and Pay for Membership button at the bottom of the page. On the next page, select the membership type (Individual or Family). You will be taken to a secure ordering page at PayPal where you can enter your billing information.

This membership permits the St. Marys Area Ambulance Service, Inc. to collect directly from any Third Party agency whatever benefits may be available. Members of our subscription program are not responsible for any balances not covered by insurance for medically necessary ambulance services. This membership entitles you the member to unlimited emergency services and limited non-emergency transportation depending on availability. Services not covered by this membership include but may not be limited to round trip inpatient hospital transportation and physician office transportation regardless of origin. Memberships will not be processed without signatures and subscriber information.

Step 1: Select Membership Type & Add Information

Membership Type (select one):

**Name:

**Address 1:

Address 2:

**City:

**State: **Zip Code:

**Telephone:

*Email Address:

**Birth Date:

**required fields - you must complete these fields

Step 2: Read Terms and Add Signature

I, the undersigned, request that payment of Medicare benefits or other insurance benefits be made on my behalf to St. Marys Area Ambulance Service, Inc. for any ambulance service provided to me by St. Marys Area Ambulance Service, Inc. I authorize any holder of medical information or documentation about me to release to the Center for Medicare and Medicaid Services and its carriers and agents, as well as to the St. Marys Area Ambulance Service, Inc. any information and documentation needed to determine these benefits or benefits payable for related services.

Typing your name and, if applicable, your spouses name below, acknowledges that you agree to the statement above and all Membership Subscription Terms of the St. Marys Ambulance Service.

**Signature:

Spouse Signature:

**required fields - you must complete these fields

Step 3: Add Family Members with Birth Dates

List family members (spouse & dependents) below:

Spouse: Birth Date:

Name 1: Birth Date:

Name 2: Birth Date:

Name 3: Birth Date:

Name 4: Birth Date:

Name 5: Birth Date:

Name 6: Birth Date:

Name 7: Birth Date:

Name 8: Birth Date:

Step 4: Submit Your Information and Pay Membership

Use the button below to submit your information and pay
your Membership Fee to the St. Marys Ambulance Service.