(1) Before transporting a nonemergency patient in an ambulance that is a rotary aircraft, an ambulance operation shall do all of the following:

    (a) Provide the nonemergency patient, or that patient’s representative, all of the following information:

    (i) Whether the ambulance operation is a participating provider with the nonemergency patient’s health benefit plan.

    (ii) A good-faith estimate of the cost for transporting the nonemergency patient.

    (iii) That the nonemergency patient has a right to be transported by a method other than an ambulance that is a rotary aircraft.

    (b) Complete the notice described in subsection (2) and, after completing the notice, obtain on the notice the signature of the nonemergency patient, or that patient’s representative, acknowledging that the nonemergency patient, or that patient’s representative, has received, has read, and understands the notice. An ambulance operation shall retain a copy of the notice required under this subdivision for not less than 7 years.

    (2) The notice required under subsection (1)(b) must be in not less than 12-point type and in substantially the following form:

    “I have been provided the following good-faith estimate of the cost of transportation by the ambulance that is a rotary aircraft that will be provided to me by _______________ (insert name of ambulance operation): _________ (insert good-faith cost estimate).

    I have been notified by _______________ (insert name of ambulance operation) that the ambulance that is a rotary aircraft that is transporting me _____ (is or is not) a participating provider with my health benefit plan.

    I was informed by _______________ (insert name of ambulance operation) that I have the right to request transportation from an ambulance operation that is a participating provider with my health benefit plan.

    I am aware that if my health benefit plan provides coverage for transportation by an ambulance that is a rotary aircraft or coverage for transportation provided by _______________ (insert name of ambulance operation), I may be subject to a deductible, a copayment, or coinsurance. If the ambulance operation is not a participating provider with my health benefit plan, I have been informed that I may be responsible for the costs of being transported by the ambulance operation that are not covered by my health benefit plan.

    I have been informed that I have the right to be transported by a method other than an ambulance that is a rotary aircraft.

_________________________________________________	___________
(Patient’s or patient representative’s signature)	(Date)
____________________________________________________________
(Type or print patient’s or patient representative’s name)”.

(3) Upon the request of a nonemergency patient’s health benefit plan or third party administrator, an ambulance operation shall provide a copy of the notice required under subsection (1)(b) to the person designated in the nonemergency patient’s health benefit plan or to the third party administrator.

    (4) If the ambulance operation fails to provide a nonemergency patient with the notice required under subsection (1)(b), the ambulance operation shall accept the amount covered by the nonemergency patient’s health benefit plan for transporting the nonemergency patient as payment in full, other than coinsurance, copayments, or deductibles.

    (5) If the patient is an emergency patient, the ambulance operation shall accept the amount covered by the emergency patient’s health benefit plan for transporting the emergency patient as payment in full, other than coinsurance, copayments, or deductibles. However, if an ambulance operation is not a participating provider with the emergency patient’s health benefit plan, the ambulance operation shall accept as payment in full the greater of the following:

    (a) The average amount negotiated by the emergency patient’s health benefit plan with participating providers for transporting the patient excluding any in-network coinsurance, copayments, or deductibles.

    (b) One hundred fifty percent of the amount that would be covered by Medicare for the emergency service, excluding any in-network coinsurance, copayments, or deductibles.

    (6) As used in this section and section 20921c:

    (a) “Health benefit plan” means that term as defined in section 21501.

    (b) “Participating provider” means that term as defined in section 21501.

    (c) “Patient’s representative” means that term as defined in section 21501.

    (d) “Third party administrator” means that term as defined in section 2 of the third party administrator act, 1984 PA 218, MCL 550.902.