Become an EMSAcare Member Step 1 of 6 16% Are you a new EMSAcare member or a returning EMSAcare member? New Member Returning Member If you are a returning member who DOES NOT need to update your information, you may use our express checkout. If you are a returning member who DOES need to update your information, please click here to make your changes.Consent(Required) I accept the Membership Agreement.Please review the linked membership agreement before proceeding.Member Name(Required)Please enter the EMSAcare Member name here. If you are a caregiver, you will enter your information on the next page. First Last Email(Required) If you already have an account, please log in to update your information. Are you applying for EMSAcare or applying for someone else?(Required) Applying for My Household Applying for Someone Else Caregiver Name(Required) First Last Caregiver Phone(Required)Caregiver Alternate PhoneCaregiver Email(Required) Billing Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How did you hear about EMSAcare?TVNewspaperWater BillPhone CallOtherOther: Please let us know how you heard about EMSAcare.Member Physical Address(Required) Same as billing address Use a different address Physical Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code This residence is a:Single Family HomeApartmentDuplexCondominiumOtherName of Apartment Complex Other (please specify) Are you in the Eastern Division or Western Division?(Required) Eastern: Tulsa Metro Area Western: Oklahoma City Metro Area HiddenBilling Address(Required) Same as physical address Use a different address HiddenBilling Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home Phone(Required)Work PhoneDate of Birth(Required) MM slash DD slash YYYY SSN(Required) GenderMFPrefer not to say Insurance QuestionsDo you have health insurance?(Required)YesNoWhich one?(Required)MedicareMedicaidOther Health InsuranceType of Insurance(Required) Policy Number(Required) Effective Dates(Required) Do you have additional health insurance?(Required)YesNoWhich one?(Required)MedicareMedicaidOther Health InsuranceType of Insurance(Required) Policy Number(Required) Effective Dates(Required) HiddenDo you have Medicare Part B?(Required)YesNoHiddenMedicare Number(Required) HiddenIs it a Medicare Replacement Plan?(Required)YesNoHiddenName of Medicare Replacement Plan(Required) HiddenMedicare Replacement Plan Identification Number(Required) HiddenDo you have Medicaid?(Required)YesNoHiddenMember ID(Required) HiddenIs it a Medicaid Managed Care Plan?(Required)YesNoHiddenName of Medicaid Managed Care Plan(Required) HiddenMedicaid Managed Care Member ID(Required) HiddenInsurance Company(Required) HiddenPolicy ID/Number(Required) HiddenGroup Number(Required) Upload Your Insurance Card Drop files here or Select files Accepted file types: jpg, png, pdf, heic, Max. file size: 50 MB. Upload a copy of your insurance cards. This is not required.HiddenAre you married?(Required)YesNoHiddenSpouse Name(Required) First Last HiddenSpouse Birthdate(Required) MM slash DD slash YYYY HiddenSpouse SSN(Required) HiddenSpouse GenderMFPrefer not to sayHiddenDoes your spouse have Medicare Part B?(Required)YesNoHiddenMedicare Number(Required) HiddenIs it a Medicare Replacement Plan?(Required)YesNoHiddenName of Medicare Replacement Plan(Required) HiddenMedicare Replacement Plan Identification Number(Required) HiddenDoes your spouse have Medicaid?(Required)YesNoHiddenMember ID(Required) HiddenIs it a Medicaid Managed Care Plan?(Required)YesNoHiddenMedicaid Managed Care Plan(Required) HiddenMedicaid Manage Care Member ID(Required) HiddenDoes your spouse have health insurance?(Required)YesNoHiddenInsurance Company(Required) HiddenPolicy ID/Number(Required) HiddenGroup Number(Required) HiddenUpload Spouse Insurance Cards Drop files here or Select files Accepted file types: png, jpg, pdf, Max. file size: 50 MB. Upload a copy of your spouse's insurance cards. This is not required. Other Permanent Household MembersPlease enter any other permanent household members in the form below. If you have none, click next. Name Birthdate Actions Edit Delete There are no Permanent Household Members. Add Permanent Household Member Maximum number of permanent household members reached. {all_fields}HiddenEMSAcare Membership ID Number HiddenLast 2 SSN By clicking submit, you acknowledge your membership will expire on August 31, 2025 unless renewed. By clicking submit, you acknowledge your membership will expire on September 30, 2025 unless renewed.
