MedStat EMS

Membership Application

Please enter the information requested and then click on the "Submit" button. The fields marked with * are required.
*Select Membership Type
Contact Information
Primary Insurance Policy
Secondary Insurance Policy
Covered Family Member 1

ex. M/D/YYYY

ex. ###-##-####

Covered Family Member 2
Covered Family Member 3
Covered Family Member 4
Covered Family Member 5
Covered Family Member 6
Covered Family Member 7
Covered Family Member 8
Payment Details

ex. MM/YY

*Terms and Conditions