APPLICATION

Name ___________________________________________

Address _________________________________ Apt. # _______________

City _____________________________ State ______ Zip Code ________

Phone ( ) ______-____________

Date of Birth ___________________________________________________

Social Security # _______________________________________________

Medicare # ____________________________________________

Other Insurance : _______________________________________

Address _________________________________ Apt. # _______________

City _____________________________ State ______ Zip Code ________

Identification # ________________________________________________

Spouse __________________________________________

Date of Birth ___________________________________________________

Social Security # _______________________________________________

Medicare # ____________________________________________

Other Insurance : _______________________________________

Dependents: Relationship

MEDICAL AUTHORIZATION/

ASSIGNMENT OF BENEFITS

I authorize any holder of medical or other information about me to release to the Health Care Financing Administration and its agents, participating EMS agency, or any insurance company, any Information needed to determine Medicare benefits or the benefits payable for related services or any other type of insurance claim, now or in the future. I permit a copy of this authorization to be used in place of the original, and request that payment available under any insurance be made directly to the participating EMS agency.

Parents sign for minors.

Signature Date

Spouse Date

Please make your check for $45 ($40 if you are over 65) payable to your local EMS agency.

If you have any questions, call us at

635-1789

and we will be happy to assist you.

Or write to:

MedGuard

c/o MultiMed

P.O. Box 535

Baldwinsville, New York 13027-0535