EMS Billing TO: EMSAC Committee Members
FROM: Jack Wampler, EMS Billing . 4,./DATE: February 14, 1990
!%
The following are comparative business figures for EMS Billing and
Collections:
Nov. 88, Dec. 88, Jan. 89
.,Billings. $514,058.51
Collections $266,523.01
% Collected 51.8*
•
Nov. 89, Dec. 89, Jan. 90
Billings $602,195.77
Collections $340,074.07
% Collected 56.5*
Billings Jan. 90 $275,875.47*
Collections $139,003.80
Billings Jan. 89 $210,295.66*
Collections $104,343.56
*Information Note: Collection percentages typically run lower during
the first six months of a fiscal year as we
experience the billing impact of the tourist season.
During the last six months, however, collection
percentages run much higher as we experience the
collections of the tourist season and the lower
summer billings.
I
_ CHARLOTTE COUNTY .
EMERGENCY MEDICAL SERVICES
SUBSCRIPTION PROGRAM.
D roues NAME ..
DATE OF BIRTH . PHONE . • .
EW U RENEWAL • IG1TY,STATE.ZIP
ESStAPT.NO. ,
SPOUSE'S MEDICARE NO.
NAME ANO 0.0.8.OF EACH.FAMILY MEMBER,OTHER THAN MYSELF.TO BE INCLUDED YOUR MEDICARE NO. •
,UG MEMBERSHIP WHO LIVES AT THE ABOVE ADO B•• F�IUACSBM SEPARATE
ESSARY)INDICATE RELATIONSHIP OF HOUSEHO YOUR BLUE CROSS/BWE SHIEID NO.,, SPOUSES BLUE CRpSSJBWE.SHIELD NO.
LIGHTER. ' DATE OF BIRTH RELATION . • GROUP NO.•
GROUP NO • 1" - •
•• • sass MAILING AOORESS BC/BS MAILING ADDRESS
,. I.. ) .i
OTHER HEALTH INSURANCE COVERAGE—Enter Name of Policy holder,•
:} '+ 't`: t • '- Plan Name and Address. Policy or Medical Assist. : • ' • • -•AYMENT: PERSONAL CHECK . 17 MDNEY ORDER. ; •,. •l t : .-• •
.
0 $30.00 Single p $60.00."Household ,
EASE COMPLETE ALL INFORMATION ON THIS APPLICATION.-. .,.
AD AND SIGN MEMBERHSIP AGREEMENT ON THE RESERVE SIDE
ID RETURN FORM WITH PAYMENT,MADE PAYABLE TO ., .".
IARLOTTE COUNTY BOARD OF COUNTY COMMISSIONERS
IO SEND TO:22429 EDGEWATER DRIVE,CHARLOTTE HARBOR. j
ORIDA 33980.1. 1•
t
- CHARLOTTE COUNTY
• EMERGENCW.MEDICAL SERVICES CONTRACT THIS PI
MEMBERSHIP FEE: I understand that the annual$60.00 .,WHO IN MY:HOME IS COVERED
thBY r IS P1
Emergency Medical The membership p
membership fee for Charlotte County out-o�pocket ex-• . household.plan limits my
Services membership p.
- for the uninsured portion of bill(s)for ambulance, .. A ho ethe� defined as husband
under the age of 18, II.
senses wife
• parent),
service provided by C.C.E.M.S. for medically necessary
balance• service originating and terminating • in � F HAVE individual.h-ouseh CL
am . I, 1
Charlotte County to or from a medical.facility. MENT: I understand that ambulance member
WHAT IS MEDICALLY NECESSARY: I understand that }
• C.C.E.M.S. membership•serviceS are restricted to the • insurance and that C.C.E.M.S.
t C. party will
agency (ea�
"medically necessary" defined as a specific need for am-._, my process. authorize
balance service transpng- on.t, er from hin health care 'Charlotte • authorize ssuch payment lto be made directly I
• .•facility (hospital, nursing. etc.) within
County where use of alternate forms of transportation surance company, I will endorse the
y transports,non-medical transport,private car, i directly to C.C.E.M.S.
• (wheel chair transport
taxi)would be medically inappropriate given the patient's
condition.C.C.E.M.S. reserves the right to require physi- EFFECTIVE DATES: I understand that my rr
clan certification of the medical necessity in cases of mem effective up receipt
October f full payment t
suspected abuse. If abuse is found to exist, I hereby �� •
understand'my'Membership.can be terminated.is good... Si nature: Date
WHERE AM I COVERED: 'The' membership . ; • g
throughout Charlotte County.and Gasprilla Island. The : ,Spouse's Signature: `'`T '` Date
membership does not cover ambulance service outside
Charlotte County, or services provided by companies The membership contract must be signet
• • other than C.C.E.M.S.
• EXCEPTION: Coverage is good for any subscription t surance Policy Holder or authorized person i
n,...,..,,lnity TLL- w..�MkINrchi IC NON-REFUNDABLE.