Ka Wai Ola - Office of Hawaiian Affairs, Volume 26, Number 11, 1 Nowemapa 2009 — Page 2 Advertisements Column 1 [ADVERTISEMENT]

HawaiiAir Ambulance/Hawaii Life FligBlhMembership Program^

What if you or a loved one neeāeā an air amhulanee?

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This Eurocopter EC-135 is one of a fleet of six rotor-wing and fixed-wing aireraft based in Koi®, Hilo, Kamuela, Kahului and Lihue; the newest and largestfleet of medical aireraft serving Hawaii. Hawaii Air Ambulance/Hawaii Life Flight Providing 2417 air amhulanee service īo īhe people ofHawaii wiīh bases in Hilo, Kamuela, Kona, Kauai anel Maui!

Hawaii Air Ambulance/Hawaii Life Flight offers exclusive meelieal air transport membership service that waives the members' insurance deductible and co-payment when we provide emergency air transportation between the Islands. Who are Hawaii Air Ambulance/Hawaii Life Flight? Hawaii Air Ambulance/Hawaii Life Flight are the premier emergency air medical services in Hawaii whieh transport people in immediate emergency medical need from one island to another. We are staffed with professional pilots, flight nurses and flight paramedics, and have been serving Hawaii since 1979.

How mueh would an air amhulanee transport cost, if I was not a member? It could be over $10,000. Why would I need transportation on an air amhulanee? If you or a family member suffered an accident or serious medical pmhlem1" and needed to be transferred to a medical facility on another island, we would provide transport! What does membership provide me and/or my family? Membership waives the patient's deductible and co-payment when we provide qualified air medical services.

How soon will my membership heeome active? Your membership becomes active on tlie date y our applieahon is signed and received by HAA/HLF. Payment must follow within 30 days. Do you accept members without health insurance? No, we do not. How do I heeome a member? Simply fill out the form and submit with the appropriate payment. 1 Services must be within our Scope of Care. Transports of some high risk OB patients and neonates do not qualify.

Our Membership saves thousands ol dollars! bor more inlormation, eall (808) 833-2270.

MEMBERSHIP PROGRAM JĒ5f A' PIease print .m. Birthdate Primary's Full Name: Month: Da\ : Year: Last First Middle Mailing Address: Email: Number and Street or P.O. Box Number City Zip Code Home Nmnber: Altemative phone Number Current Heahh Insurace Provider NOTE: We do NOT accept applicants witliout heahli insurance. Pe1ationshin Family Member Name Current Heahh Birthdate P (Spouse, dependents to age 18 imless full time shident to 23) Insurance Provider Month Day Year Senior rates apply to those 55 years of age or older. Senior Family rates require at least one senior witliin the household. |SENIORYEARLYRATES (checkbox) |REGULAR YEARLY RATES tcheckbox) Family rates include 2-4 members Additional Dependents Family rates include 2-4 members Additional Dependents □ Single $49 (per year) n/a □ Single $59 (per year) n/a □ 1 vear $79/famiiy $20 □ 1 vear $99/familv $20 □ 2 vears $139/familv $40 □ 2 vears $179/familv $40 !□ 3 vears $199/familv $60 !□ 3 vears $259/family $60 Conditions ofMembership I understand this membership is a service agreement with Hawaii Air Ambulance/Hawaii Life Flight (HAA/HLF) and this member services brochure fully explains the air ambulance services provided by HAA/HLF. All services covered by this membership must be arranged through HAA/HLF and must be within HAA/HLF scope of care, and the services provided under this membership constitutes all services available under this agreement. I understand the medical necessity of all flights will be determined by certification of an attending physician and HAA/HLF medical directors. I understand that HAA/HLF cannot be held liable should another carrier be chosen to provide the transport for any reason whatsoever. The member's entire co-payment and deductible will be "waived" after all insurance providers have made appropriate payments and membership fees are paid in full. Any insurance payment made by an insurance provider and sent to the member must be submitted to HAA/HLF. Membership fees are due within thirty days (30) of this application date. Conditions & prices are subject to change. I hereby authorize the release of any and all medical information necessary to determine the suitability for air transportation. Signature: Date: Mail Application and Payment to: HAA/HLF For more information? eall 808-833-2270 or go to P.O. Box 30242 hiairamb.com or email to Honolulu, HI 96820 customerservice@hawaiiairambulance.com r/8