Fire Med Application

NOTE: If you are renewing a current membership, you may make a one-time payment by credit card with no fees on this website or by calling 844-364-9966 (prepare to have your Customer and Account Number ready)

Yes! I want to join FireMed!
Membership is available to all residents of Huntington Beach. The membership fee covers all people who live at the residence.

Please select billing type below:

Add the $5 monthly payment to my Municipal Services Statement
Municipal Services Statement must be in the same name as noted in applicant
information below

Bill me annually for $60

(a low-income membership rate is available - please contact our office for details)
* = required

First Name *

Last Name *

Home Address

(Just one person's name from the household is required, and will be used for contact purposes only. FireMed membership is confirmed by the home address in Huntington Beach, not the name submitted on the membership application.)

Street Number *

Street Name*

Apt./Unit #

City
HUNTINGTON BEACH

Zip Code *

Home Phone Number *

Alternate Phone Number

Type

Number in Household *
This number is used only to provide the correct number of Medical Information forms for each permanent household member