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 RateWho 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*October 1, 2019November 1, 2019December 1, 2019Group 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*YesNoError Counter: Non-Medicare Senior Citizen without groupNotice: Any non-Medicare individuals over 65 must come with a group in order to be eligible for AHS membership. 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.Total Monthly CostIndividual CalculationMyself & Spouse CalculationMyself & Dependents CalculationFamily CalculationSenior Citizen CalculationSenior Citizen & Spouse CalculationTotal(This does not include the one-time $100 enrollment fee per household.) Monthly Cost: $0.00
