AHS Member Application

AHS Member Application
Statement of Faith
As an Anabaptist medical sharing group, we share these commonly held beliefs:
- 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 as well as modesty in dress. It is required for membership that our Member ladies wear the veiling and skirts consistently on a daily basis.
Please check the box below if you agree and adhere to all the 7 Statements of Faith listed above:*

I agree

Program
Choose your healthshare plan*
Who will the plan be for?*
When would you like to start?*

MonthDayYear
Please choose the first of a month.
Are all applicants US citizens?*

YesNo
Do all applicants have social security numbers?*

YesNo
Important

AHS requires all members to have US citizenship and a social security number. If you would like to continue your application process, please contact our office at 540-738-2640 for further discussion.
Please describe any pre-existing medical conditions you have*
Type na if you don't have any.
I am with an existing AHS group*

YesNo
Group Name
Do you need the Worker’s Aid add-on for work related injuries?*

YesNoI'm not sure

Personal
Name*

First NameMiddle NameLast Name
Marital Status*
Church Name and Affiliation*
Include your affiliation (type of church).
Deacon's Name and Contact Information*
Date of Birth*

MonthDayYear
Are you 65 or older?

Yes, I am 65 or older
Do you have Medicare A & B?

YesNo
Do you have Medicare D?

YesNo
Are you social security exempt?*

YesNo
⚠︎ Ineligible to Join ⚠︎

Anabaptist HealthShare is currently not enrolling members who are social security exempt and not part of an existing group. Please contact our office if you are interested in joining with a group and have questions about that process.
Phone Number*
Email

Confirmation Email
Address*

Street Address

Street Address Line 2

CityState

Zip Code

Signature
Medical Bill Policy

AHS is not insurance. The AHS team members serve as Patient Advocates for members of the sharing program in resolving medical bills. It is the policy of AHS to utilize the best available path provided by a hospital to reach the bottom line of a member's bill. This path could include using: self-pay rates, income-based rates, Medicaid, Medicare, Financial Assistance, catastrophic bill rates, plain community pricing, etc. All bills remain a member’s bills. AHS is not a guarantor of payment. All members of AHS agree to fully cooperate with the AHS Patient Advocates as they work with hospitals to find the final amount owed for bills. This could include submitting tax forms to verify income, etc., as required by a hospital. If a member would rather find their own path in getting to the bottom line for a bill, that bill becomes the full responsibility of the member and will not be a shareable bill in the AHS program.

By signing below, I aﬃrm that this Medical Sharing Application is true and complete to the best of my knowledge, that I am in adherence with the Statement of Faith and Practice, and that I agree to comply with the Medical Bill policy. If, at any time, I no longer adhere to the Statement of Faith and Practice, I agree to promptly notify AHS.

I also hereby authorize AHS to contact my group representative or other church leader to discuss my medical bills or sharing requests.
I agree to Anabaptist HealthShare terms and conditions.
Signature*
Date*

MonthDayYear
Additional Information (optional)
Should be Empty:

AHS Member Application

Statement of Faith

As an Anabaptist medical sharing group, we share these commonly held beliefs:

Program

Important

Personal

⚠︎ Ineligible to Join ⚠︎

Family Information

Important

If you have more than 10 children, please contact our office and we can assist in adding your other children to your account.

Signature

Medical Bill Policy