LIFE FLIGHT NETWORK
PO BOX 3841, Portland, OR 97208-3841
Phone: 800-982-9299 | Fax: 503-678-4369
GIFT MEMBERSHIP
GIFT PROVIDER CONTACT INFORMATION
MAIL GIFT MEMBERSHIP TO
MAIL MEMBERSHIP RENEWAL TO
KEY MEMBERSHIP TERMS
Membership fees are non-refundable, non-transferable and not tax
deductible. Eligible household members must be listed on the
Membership record at the time services are rendered to be eligible for
benefits. Terms and conditions are subject to change. For current terms,
see www.lifeflight.org
A Life Flight Network Membership is not an insurance policy, but
Yes, I am purchasing this Membership as a gift
New Member and lapsed Member benefits take effect 72 hours after
Emergency air medical transports are based on medical need, not
Membership status. Medical need can only be determined by a
physician, EMS provider, hospital or another qualified third-party
recognized by Medicare.
period for a lapsed Membership.
*My authorization to annually charge the account indicated, up to one month prior to
my expiration date, shall remain in effect until I notify Life Flight Network that I wish to
change or end it. A record of each payment will appear on my credit card statement
and will serve as my receipt.
Courtesy Membership ID cards including a Statement of Understanding
and receipt will be mailed after receipt of application and payment.
By becoming a Life Flight Network Member, you agree to the Membership
terms listed below as well as the complete Statement of Understanding,
which can be reviewed at www.lifeflight.org
22285 Yellow Gate Lane, Suite 102
Aurora, OR 97002
WWW.LIFEFLIGHT.ORG
Idaho
Montana
Oregon
Washington
Life Flight Network Members rest easy
knowing a medically necessary and
emergent air medical ight for themselves
or family members will not add a nancial
hardship. Life Flight Network works directly
with your insurance company for their
portion of the payment, and the rest is
covered by your Membership.
WWW.LIFEFLIGHT.ORG
LFN-MBNEW-006
Serving the region operating out of bases located in:
Emergency Air Medical Transport
Aviation services provided by Life Flight Network and Jackson Jet Center.
One Year: $65
Two Years: $120
One Year: $65 Auto Renew
Five Years: $275
Lifetime: $1,000
If this is a gift Membership, complete the back of the application
*List additional Members on separate sheet if necessary
By selecting the auto nenew option I authorize Life Flight Network to make annual
recurring payments to the credit card provided. * See full statement on back.
Kelso
Newport
Richland
Kennewick
Life Flight Network is a nationally recognized,
not-for-prot air medical service with bases in
Idaho, Montana, Oregon, and Washington.
Our adult and neonatal critical care teams
prove every day they are among the very
nest in the nation. When we are called to
provide medical transport our ight team
serves as a mobile intensive care unit with
one purpose - to save lives. Our teams are
trained and have experience to care for
a wide variety of patients, including high
risk obstetrical emergencies, heart attacks,
strokes, traumatic injuries, and premature
newborns.
Life Flight Network’s Membership program
provides nancial peace of mind for more
than 140,000 households. Life Flight Network
has transported more than 120,000 patients
over nearly four decades of operation
and is committed to establishing bases in
communities where we are most needed.
Medical emergencies happen every day
without warning. If EMS or health care
providers determine emergency air medical
transport is needed and you are own by
Life Flight Network, your Membership protects
you and your family from having any out-
of-pocket expenses. Life saving air medical
transport can be expensive, and health
insurance may not cover all costs. Life Flight
Network works directly with your insurance
company (if any) for their portion of the
payment and the rest of the cost is covered
by your Membership.
Life Flight Network Members are also covered
by reciprocal agreements with other regional
air medical transport organizations in Idaho,
Washington, western and central Montana,
northern Nevada, northern California, and
southeast Alaska, subject to the reciprocal
program’s Membership rules. To view a
current list of our reciprocal programs, please
visit www.lifeight.org
How Does Membership Work? Membership Benets
Reciprocal Agreements Expand
Coverage
Emergency Medical Calls: Always call
911 when you need emergency medical
assistance. A physician, EMS provider or other
authorized personnel will determine if Life
Flight Network is needed.
Para información en español sobre la membresia
de transporte de emergencia, favor de llamar a
nuestra ocina de membresia al 800-982-9299.
We invite you to become a Life Flight
Network Member or give Membership
as a gift to the ones you love.
To enroll today, simply go to:
www.lifeight.org/membership, ll
out the online form, and pay by credit
or debit card. It’s simple, secure, and
easy to use.
If you prefer, you may ll out the
Membership application in this
brochure and mail it in at your
convenience.
Life Flight Network Membership benets
cover you, your spouse or domestic
partner, and dependents claimed on
your income tax return. Elderly or disabled
family members living in the same
household are also covered.
There are no out-of-pocket expenses for
emergent, medically necessary ights.
You are covered by all Life Flight Network
bases in Idaho, Montana, Oregon, and
Washington, as well as our reciprocal
partners.
Rev. 0817
GROUP MEMBERSHIP APPLICATION
SEIU Local 503
MEMBER ENROLLMENT INFORMATION
Member Name:
Date of Birth:
Spouse/Domestic Partner:
Date of Birth:
Mailing Address:
City:
State:
Zip:
Phone:
Email Address:
Additional Household Members:
Includes any dependents claimed on your tax return and elderly or disabled family members living in the same household
Date of Birth
Relationship
DISCOUNT GROUP MEMBERSHIP RATE
$50 – 1 Year
_____ I am an existing member. ID# (if known)___________________
Return this application and payment by 10/31/2017 to:
Member Benefits, PO Box 12159, Salem OR 97309
Please make check or money order payable to: SEIU Member Benefits.
If you have questions about enrollment contact SEIU Local 503 Member Benefits at (503) 540-8460.
LIFE FLIGHT NETWORK FOUNDATION
P.O. Box 3841 • Portland, Oregon 97208-3841
Phone: (503) 678-4370 • Fax: (503) 678-4369
This application is valid through 10/31/2017. Payment will be forwarded by SEIU Member Benefits to Life Flight Network for enrollment for calendar year 2018. Life
Flight Network transports patients based on medical need, not membership status. Medicaid beneficiaries should not apply for membership. Aviation services
provided by Life Flight Network and Jackson Jet Center.
Rev. 0817
STATEMENT OF UNDERSTANDING
By becoming a Life Flight Network and/or FireMed Member, you agree to the terms stated below.
Life Flight Network and/or FireMed Membership benefits are extended to the primary member, his/her spouse or
domestic partner and their dependents claimed on their income tax return. Elderly or disabled family members living
in the same household are also covered.
The first person listed on the application form is designated as
the “Primary Member”. Only those persons who meet the
membership eligibility requirements AND are listed in the
membership record at the time services are rendered are
eligible for benefits. Per government regulations, individuals
covered by Medicaid are not eligible for membership and
should not apply.
Life Flight Network and/or FireMed Memberships are not an
insurance policy but secondary to insurance carriers. All
available insurances will be billed first. We will accept payment
from insurance carriers as payment in full.
Life Flight Network Memberships are honored by several
regional air transport reciprocal partners. Your Life Flight
Network Membership covers air transport when emergently
transported in a Life Flight Network aircraft. Reciprocity
between regional air membership programs is subject to the
reciprocating program’s rules.
Ground Memberships are honored by FireMed Membership programs of Oregon. Ground Membership covers
ground ambulance charges only.
Both air and ground emergent 9-1-1 and interfacility transports are based on medical need, not membership status.
Patients are transported to the closest medically appropriate facility as requested by the physician or EMS system.
Non-emergent transports are not covered by this agreement.
Availability of service cannot be guaranteed due to weather conditions, commitment to another transport or aircraft
out-of-service.
No refunds will be issued on Membership purchases. Membership benefits are non-transferrable.
Renewal payments must be received prior to the expiration date to avoid a lapse in benefits. There is no grace
period.
New and lapsed Membership benefits take effect 72 hours after receipt by Life Flight Network of a completed
enrollment form with payment.
Membership fees are not tax-deductible.
I transfer directly to Life Flight Network and/or the FireMed Agency my rights to air and/or ground insurance
payments due to me for services provided by Life Flight Network and/or the FireMed Agency. Such payments shall
not exceed Life Flight Network and/or FireMed regular charges.
I specifically waive any and all rights, claims or causes of action against Life Flight Network and/or the FireMed
Agency and its employees and agents with respect to my Life Flight Network and/or FireMed Membership and the
Life Flight Network and/or FireMed Membership Program.
The Membership Program may be canceled at any time for any reason, including financial feasibility and
governmental regulation of such programs. Terms and conditions are subject to change. For current terms see
www.lifeflight.org
There. When you need us. www.lifeflight.org
LIFE FLIGHT NETWORK LOCATIONS
