Application Total ErrorsSelect 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*November 1, 2019December 1, 2019January 1, 2020Group RateA group consists of 10 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 DiscountMy InformationChurch or Ministry or Employer*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 groupImportant: Any 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 My 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 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
