IAA Membership

  Provider Information:
Company:
Address:
City: County: State: Zip:
Contact: Title:
Phone: Fax: Email:
 Business Category:
Check all that apply:
Fire Department Individual/Corporate Owned Public Provider
Hospital Based Municipal Volunteer
Other
How Are You Governed? (Check ONE)
City Contract County Ordinance Other:
City Ordinance Labor Contract
County Contract Public Utility
Number of Indiana Certified?
EMT's: Advanced EMT's Paramedics:

Year Ambulance Service Started: Number of Certified Ambulances:
Provider Certification Number: Medicare Provider Number:
 Membership Type:
Check One
Active
Providers currently ceritified by the State of Indiana to provide ambulance service. Active membership dues are based on the number of ambulances.
1-3 Ambulances
4-6 Ambulances
7 or more
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$175.00 Per Year
$350.00 Per Year
$525.00 Per Year
Affiliate $100.00 Per Year
Any person, partnership, corporation or other entity engaged in the manufacture, sale, rental, furnishing or servicing of equipment or services utilized in the delivery of medical transportation. 
Associate $50.00 Per Year
Any governmental, hospital, person, partnership, corporation, or other entity not engaged in the delivery of medical transportation or not meeting the above classes, who has a desire to become active in the IAA, and meets the standards as may be set forth by the Board of Directors.


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