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Ambulance Subscription Program

File Ambulance Subscription Information Letter
An overview of the program.
File Ambulance Subscription Enrollment Form
This is for initial enrollment in the program. Please submit with payment, copies of drivers licenses, health insurance cards and a signed Assignment of Benefits form.
File Assignment of Benefits and Privacy Acknowledgement Form (HIPAA)
This HIPAA form must be signed and returned with your enrollment form.
File GVFD Notice of Privacy Practices (HIPAA)
This Notice describes how medical information about you may be used and disclosed and how you can get access to this information. This is informational only and does not need to be signed. This is for you to print and keep.
File GVFD Privacy Practices (HIPAA)
This Notice describes your legal rights, advises you of our privacy practices, and lets you know how GVFD/EMS Service is permitted to use and disclose Personal Health Information about you. This is informational only and does not need to be signed. This is for you to print and keep.
File Ambulance Subscription Program RENEWAL FORM
If you are already a subscriber and need to renew for 2016, please use this form.
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