Apply Now - Anabaptist Healthshare

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Our Statement of Faith*
As an Anabaptist medical sharing group, we share these commonly held beliefs:
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- 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
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.

My Information
Church or Ministry or Employer*
My Name*
First Last
My Date of Birth*
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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 Medicare
- Yes
- No
Error Counter: Non-Medicare Senior Citizen without group
Error Counter: Non-Medicare Senior Citizen without group
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.
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 ZIP Code
Phone*
Email*
My Spouse's Information
Spouse'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 group
My Dependents
Children under 18
Children at home who are over 18 must purchase their own individual plan.
Name Date of Birth
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Delete
There are no Children.
Maximum number of children reached.

Name	Date of Birth
		Edit Delete
There are no Children.

Medical Conditions
Medical Conditions
Please 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 Cost
Individual Calculation
Myself & Spouse Calculation
Myself & Dependents Calculation
Family Calculation
Senior Citizen Calculation
Senior Citizen Calculation - No Medishare
Senior Citizen & Spouse Calculation
Senior Citizen & Spouse Calculation - No Medishare
Total
(This does not include the one-time $100 enrollment fee per household.)
Monthly Cost: $0.00

My Information