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    Agreement For Medical Transportation

    Uploaded by

    Joga Bonita
    This document outlines an agreement between Ashoka Rescue Air Ambulance Services and a patient for emergency air ambulance transportation and medical services. It details the medical team that will accompany the patient, the route, total costs, terms of payment, and responsibilities of both parties. Key terms include provision of ground and air ambulance transport, medical escorts, equipment and supplies for the patient's needs, and processing of necessary clearances for travel. The agreement is signed by both the patient and service provider director to authorize the emergency medical evacuation services.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Agreement For Medical Transportation

    Uploaded by

    Joga Bonita
    587 views4 pages
    This document outlines an agreement between Ashoka Rescue Air Ambulance Services and a patient for emergency air ambulance transportation and medical services. It details the medical team that will accompany the patient, the route, total costs, terms of payment, and responsibilities of both parties. Key terms include provision of ground and air ambulance transport, medical escorts, equipment and supplies for the patient's needs, and processing of necessary clearances for travel. The agreement is signed by both the patient and service provider director to authorize the emergency medical evacuation services.

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    Agreement-for-Medical-Transportation

    Original Title

    Agreement-for-Medical-Transportation

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    This document outlines an agreement between Ashoka Rescue Air Ambulance Services and a patient for emergency air ambulance transportation and medical services. It details the medical team that will accompany the patient, the route, total costs, terms of payment, and responsibilities of both parties. Key terms include provision of ground and air ambulance transport, medical escorts, equipment and supplies for the patient's needs, and processing of necessary clearances for travel. The agreement is signed by both the patient and service provider director to authorize the emergency medical evacuation services.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    587 views4 pages

    Agreement For Medical Transportation

    Uploaded by

    Joga Bonita
    This document outlines an agreement between Ashoka Rescue Air Ambulance Services and a patient for emergency air ambulance transportation and medical services. It details the medical team that will accompany the patient, the route, total costs, terms of payment, and responsibilities of both parties. Key terms include provision of ground and air ambulance transport, medical escorts, equipment and supplies for the patient's needs, and processing of necessary clearances for travel. The agreement is signed by both the patient and service provider director to authorize the emergency medical evacuation services.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    The key takeaways are that the document outlines an agreement between Ashoka Rescue Air Ambulance Services and a patient for emergency medical transportation and air ambulance services. It details the scope of work, terms, conditions, signatures, and witnesses of the agreement.

    The agreement covers the emergency medical evacuation of the patient by Ashoka Rescue Air Ambulance Services under medical assistance. It will provide ground and air transportation, medical escorts and equipment for the transfer.

    The terms of payment include advance payment by net banking, bank cheque or ICICI bank account. The total cost is specified in Indian Rupees (INR).

    Agreement for Medical Transportation:

    EMERGENCY MEDICAL SERVICES, AIR AMBULANCE SERVICE PROVIDER AGREEMENT

    BETWEEN

    ASHOKA RESCUE AIR AMBULANCE SERVICES Pvt Ltd

    AND

    Patient .........................................................................

    ASHOKA RESCUE AIR AMBULANCE SERVICES


    .

    (DR.ASHOK KUMAR. The Director)

    J-37, KHIRKI EXTENSION, MALVIYA NAGAR, NEW DELHI-110017. INDIA

    This Emergency Medical Services and Air Ambulance Service Agreement

    (The "Agreement") is made by and between ASHOKA RESCUE AIR AMBULANCE SERVICES, ("Provider"),
    and patient / MR....................................................................................., with respect to the provision of
    emergency medical and Air Ambulance Services (As a stretcher case in Charter Aircraft with medical
    escort doctor and one paramedic) to support the emergency and medical needs OF patient
    MR / Mrs ................................................................... who is admitted
    .......................................................................................................................India.

    ASHOKA RESCUE is assisting us to transfer patient MR Mrs Ms.........................................................

    As per agreed terms & total cost of the services is INR........................................................................ for

    •Stretcher Ticket

    •Medical Escort To & Fro...

    As per condition of the patient risk of the transfer explained to her and relatives.

    Both the parties are here by agreeing upon the mutual contract of medical evacuation of patient

    MR Mrs. Ms......................................................................................
    SCOPE OF WORK

    The basis of this Agreement is the desire and intention of the Parties to provide emergency medical
    evacuation to the patient MR Mrs. Ms....................................................................................Under
    medical assistance by ASHOKA RESCUE Air Ambulance Services and in lieu Medical emergency
    evacuation fees as per the Quotation stated below.

    Total cost: INR ………………………………………………. Detailed Invoice provided.

    The patient will be transferred by ASHOKA RESCUE Air Ambulance Services under supervision of
    following medical team:

    Medical Team:

    1. Dr.

    2. Dr.

    Aircraft Type:

    Airline type:

    Route:

    TERMS AND CONDITIONS:

    1. Ashoka Rescue will do the complete formality of

    •stretcher in commercial airline

    Or

    •charter aircraft including medical clearance with airline medical team.

    2. Ashoka Rescue AIR AMBULANCE SERVICES shall provide ground ambulance from

    3. Ground ambulance at …………………………………………………..

    4. Ashoka Rescue Medical team will carry all medical equipment with resuscitation kit.

    5. Ashoka Rescue will provide

    •Medical Escort

    •Paramedic
    .

    6. Above mentioned quote includes:

    •Medical Doctor

    •Medical Escort

    •Ambulance at ...........................................................................

    •Air Ambucare

    Or

    •Commercial Stretcher/ flatbed cost,

    •One attendant ticket.

    •Medical Escort return ticket.

    •Processing Fess of the agency.

    7. Repatriation is subject to Medical clearance from airline.

    8. SPECIAL ADVISORY:

    IN CASE OF STRETCHER IN COMMERCIAL AIRLINES/AIR AMBULANCE BY CHARTER AIRCRAFT,


    CANCELLATION DUE TO THE DETORIATION OF PATIENT HEALTH STATUS, STRETCHER, OXYGEN AND ALL
    TICKETING COST WILL BE NON REFUNDABLE SUBJECT TO AIRLINE STANDARD RULES.

    9. Account details mentioned below:

    For Net banking / bank Cheque in advance .
ICICI Bank

    Account No. 022405002106

    Account Type: Current Account

    Account Name: Ashoka Rescue Air Ambulance Services P L

    Branch; N-138

    Panchsheel Park, New Delhi- 110017, (INDIA)

    IFSC code: ICIC0000224

    Pan no, AAICA5222H

    Swift Code : ICICINBBCTS

    Email : [email protected]
    10. Entire Agreement: This document represents the entire Agreement between the parties. All prior
    negotiations and written and or oral agreements between the parties with respect to the subject matter
    of the agreement are merged into this Agreement.

    11. Governing Law, Venue. This Agreement has been executed and delivered in, and shall be construed
    and enforced subject to New Delhi jurisdiction only.

    IN WITNESS WHEREOF, this Agreement is entered into the day of Date.............month ................year
    2017 by the Patient..............................................................................

    Family member with relation with patient :

    And

    Ashoka rescue AIR AMBULANCE SERVICE

    Accepted & Signature by: ………………………………………………….

    Name………………………………………….

    Patient MRs /MS /MR

    Accepted & Signature by: ………………………………………………….

    Name Dr. Ashok Kumar.

    Director

    Ashoka Rescue AIR AMBULANCE SERVICES

    Witnessed By:

    Witness Signature 1: ……………………………………….

    Name:………………………………………………………..

    Witness Signature 2: ……………………………………….

    Name:……………………………………………………

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