Application Step 1 of 4 - Statement of Faith 0% Total ErrorsOur Statement of Faith*As an Anabaptist medical sharing group, we share these commonly held beliefs: Select All We believe in the biblical principle of sharing with those who experience medical needs. Galatians 6:2 We believe in the sanctity and dignity of human life, and that God created every life for a special meaning and purpose. Psalms 139:13-14 We believe that our bodies are the temples of the Holy Ghost, and that it is our responsibility to God and our fellow members to exemplify Christ in every aspect of life,including choices and habits that affect our health, and to avoid habits and behaviors that are harmful to the body. 1 Corinthians 6:19-20 We believe in the power of prayer and that prayer should be a conviction and faithful practice of our daily lives. 1 John 5:14 We believe in a God who cares for his people through sickness and health. He is the Great Physician and the Provider of all our needs. He is Joy in sorrow, a Comfort in pain,and our ever-present Help in times of trouble.1 Peter 5:7 We believe in the Anabaptist practice of nonresistance as a way of life. This is expressed by not taking up arms, by not initiating lawsuits, and by not engaging in retaliation of any kind. Matthew 5:39 We believe in and practice the 1 Corinthians 11 teaching on the headship veiling. Electronic Signature*By signing below, we affirm this Medical Sharing Application to be true and complete to the best of our knowledge, and that we are in adherence with the Statement of Faith And Practice. Head of household signature required. Select Program*For further details about each program, view our Programs page.CatastrophicStandardCompleteIndividual Catastrophic RateIndividual Standard RateIndividual Complete RateSelected Program: Individual RateFamily Catastrophic RateFamily Standard RateFamily Complete RateSelected Program: Family RateSenior Citizens Standard RateSenior Citizens Complete RateSelected Program: Senior Citizens RateSelected Program: Senior Citizens Rate - No MedishareWho will be on this membership?*MyselfMyself & my spouseMyself & my dependentsMyself, my spouse, & my dependentsSocial Security exempt?*Has anyone who will be a part of this program filed a government exemption from Social Security?YesNoIndividual Exemption FeeFamily Exemption FeeDesired Start Date*May 1, 2020June 1, 2020July 1, 2020Group RateA group consists of 20 or more paying members, not including children under 18. I am part of a group Group Name*Individual Standard Group DiscountIndividual Complete Group DiscountFamily Standard Group DiscountFamily Complete Group DiscountTotal Group Discount My InformationChurch Name and Affiliation*My Name* First Last My Date of Birth* MM DD YYYY I am enrolled in Medicare parts A and B*Only click "Yes" if you are enrolled in both parts A and B of MedicareYesNoError Counter: Non-Medicare Senior Citizen without groupError Counter: Non-Medicare Senior Citizen without groupImportant: Any Social Security Exempt / non-Medicare individuals over 60 must come with a group in order to be eligible for AHS membership. Important: Any Social Security Exempt / non-Medicare individuals over 60 must come with a group in order to be eligible for AHS membership. Note: Members 65 and older who do not enroll in both Medicare parts A and B will experience a 75/25% sharing of the cost after ISA is met.Note: There is a 75/25% sharing of the cost for non-Medicare members over 65 after ISA is met. Mailing Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone*Email* My Spouse's InformationSpouse's Name* First Last Spouse's Date of Birth* MM DD YYYY Important: Any Social Security Exempt / non-Medicare individuals over 60 must come with a group in order to be eligible for AHS membership. Error Counter: Spouse Non-Medicare Senior Citizen without groupMy DependentsChildren under 18Children at home who are over 18 must purchase their own individual plan. Name Date of Birth Edit Delete There are no Children. Add Child Maximum number of children reached. Medical ConditionsMedical ConditionsPlease list any pre-existing conditions such as cancer, chronic illnesses, etc. Include current and projected treatment needs.Important: Any Social Security Exempt / non-Medicare individuals over 60 must come with a group in order to be eligible for AHS membership. Important: Any Social Security Exempt / non-Medicare individuals over 60 must come with a group in order to be eligible for AHS membership. Total Monthly CostIndividual CalculationMyself & Spouse CalculationMyself & Dependents CalculationFamily CalculationSenior Citizen CalculationSenior Citizen Calculation - No MedishareSenior Citizen & Spouse CalculationSenior Citizen & Spouse Calculation - No MedishareTotal(This does not include the one-time $100 enrollment fee per household.) Monthly Cost: $0.00
