Charlestown Ambulance-Rescue Service

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Annual Donation Drive - 2021

2021 Annual Donation Drive 

Individual $35.00

Household $70.00

Business enrollment is $120.00 for the first twenty-five (25) employees, plus an additional $60.00 for each twenty-five (25) employees above that staff size. The same rules apply for billing of the employees' health insurance with the business contribution covering anything not paid by health insurance.

We certainly hope that we can count on your contribution again this year. It is greatly needed and appreciated so that we can continue to provide the best quality emergency medical and rescue services when you need them.

Charlestown Ambulance will provide emergency service with transportation to the closest appropriate facility. Contributors must live in the Charlestown area or adjacent community. The ambulance service also must start or end in these communities. Emergency services will be provided when Charlestown Ambulance Service is directed by police, doctors, or emergency requests.

Charlestown Ambulance will provide routine ambulance service within 100 miles of Charlestown. Routine ambulance service must be medically necessary and must be scheduled twenty-four (24) hours in advance. Routine services may be subcontracted at no cost to the contributor. Routine service by Charlestown Ambulance must be at the direction of a physician, hospital or other health care facility.

Charlestown Ambulance will provide routine ambulance service to points outside the 100-mile radius and will charge additional mileage fees not covered by this contribution. The ambulance will not be delayed more than the normal time it takes to load and/or unload the patient.

Charlestown Ambulance reserves the right to submit a claim to the contributor’s insurance carrier and agrees to accept assignment at no further cost to the contributor.

Emergency and routine ambulance service to non-contributors will be subject to additional fees that may not be fully covered by health insurance.

Charlestown Ambulance will not provide transportation to hospitals or other health care facilities for elective diagnostic procedures, or to any treatment or therapy facility on a continuing basis.

Required   Indicates Required Field
Date/Time: Required 04/15/2021 1052
Name: Required
Date of Birth (MM/DD/YYYY): Required
Email Address: Required
House Number: Required
Street Name: Required
Address Line 2:
Town: Required
Zip Code: Required
Phone Number: Required
Name of Family Member #1:
Date of Birth of Family Member #1:
Name of Family Member #2:
Date of Birth of Family Member #2:
Name of Family Member #3:
Date of Birth of Family Member #3:
Name of Family Member #4:
Date of Birth of Family Member #4:
Name of Family Member #5:
Date of Birth of Family Member #5:
Donation Amount: Required $35 Single
$70 Family
$120 Business

Upon Successful completion of this form you will be directed to PayPal to submit payment.





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Charlestown Ambulance-Rescue Service
4891 Old Post Road
PO Box 346
Charlestown, RI 02813
Emergency: Dial 911
Non-Emergency: 401-364-3742
E-mail: website@charlestownrescue.org
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