9.jpg

lfn-logo-smFireMed Coverage Map
Click image to enlarge
firemed-map
       firemed-logo-sm

Membership offers peace of mind for unexpected emergency transport expenses. Benefits cover you, your spouse or domestic partner and dependents claimed on your income tax. Elderly or disabled family members living in the same household are also covered. If transported, we simply bill your insurance. There are no deductibles and no extra co-pays.

Your membership fees help enhance EMS services in La Grande by allowing us to invest in the latest life-saving equipment and highly skilled personnel. Thank you for supporting our local EMS agencies.

Your FIREMED BASIC membership covers you and your household in over 64,500 square miles of Oregon. Your FIREMED PLUS membership includes all FireMed Basic services as well as air medical transport coverage in over 200,000 square miles of Life Flight Network’s service area throughout the Pacific Northwest and Intermountain West.

By becoming a FireMed member, you agree to the terms stated in the Statement of Understanding. New member benefits take effect 72 hours after receipt of completed application and payment. Life Flight Network transports patients based on medical need, not membership status. Medicaid beneficiaries should not apply for membership.

This form is hosted on our secure server and all information is encrypted using SSL for your personal data privacy and security.

STEP 1: MEMBER INFORMATION / PAYMENT » STEP 2. RECEIPT / CONFIRMATION

Note: All fields with (*) are required.

Membership Information

Choose one membership type*

Please Select
If renewing membership, enter Membership ID Invalid Input

La Grande FireMed BASIC La Grande FireMed PLUS
Invalid Input Invalid Input
By selecting the auto renew option, I authorize Life Flight Network to make annual recurring payments to the credit card provided. See further details at bottom of this form.**

Invalid Input

Invalid Input

Member Information

Primary Member First Name* You must enter a first name.
Last Name* You must enter a last name.
Date of Birth (mm/dd/yyyy)* Invalid Input
Spouse/Domestic Partner Invalid Input
Date of Birth (mm/dd/yyyy) Invalid Input
Mailing Address* You must supply an address.
City* You must supply a city.
State*Please select a state.
Zip Code*You must supply a zip code.
Phone*You must supply a phone number.
Email*You must provide an email address.

(Will be used to provide confirmation of membership payment as well as sign you up for our membership Enewsletter)


Dependents

Dependents are defined as unmarried dependents you claim on your income tax return.
NameDate of Birth (mm/dd/yyyy)
#1: Invalid InputInvalid Input
#2: Invalid InputInvalid Input
#3: Invalid InputInvalid Input
#4: Invalid InputInvalid Input
#5: Invalid InputInvalid Input
Please call our membership office if you have additional dependents to add.

Gift Information (if applicable)

Gift Giver NameInvalid Input
Mailing AddressInvalid Input
CityInvalid Input
StateInvalid Input
Zip CodeInvalid Input
PhoneInvalid Input
EmailYou must provide an email address.
Invalid Input
Invalid Input

Other Information


How did you hear about Life Flight Network Membership?*
Invalid Input
If Other, please specify:
Invalid Input

Payment Information

Credit Card Type*
Invalid Input




Please press PROCEED TO PAYMENT only once to ensure proper processing of your information. Clicking "Proceed to Payment" will redirect you to Life Flight Network's secure payment system, where you can complete your order using your credit card or PayPal account. Membership purchases are non refundable and non transferable.

**If renewing membership automatically: I hereby authorize my financial institution to make annual recurring payments from the credit card account listed above up to 1 month prior to my expiration date in the amount indicated on this form for a 1 year membership. I will notify Life Flight Network in writing if I decide to discontinue this service or change or close my credit card account. I certify that I am an authorized user of this credit card and will not dispute the scheduled payments with my credit card company provided the transactions correspond to the terms indicated in this authorization form.