The Shared Health Alliance Preventive program is built to make any Health Share Program a more complete solution. Includes $10/20%/40% Rx program, $50 MRA Virtual Primary Care. Program includes 100% sharing for ACA required list of preventive care services.
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Thank you for enrolling in an ASH program! We endeavor to clarify as much as possible the process and obligations between us and have found that providing this confirmation is one of the best ways to start the relationship. Please review and acknowledge your understanding of the below. Once completed, a copy of this form will be provided in the member portal for your records.
By enrolling today, I agree and affirm I am enrolling for the sole purpose the programs are intended for and further affirm I was contacted because I provided my contact information for this very purpose. I further affirm I am not enrolling for the purpose of making threats or demands for money by alleging violations of the telephone consumer protection act and/or federal trade commission do not call registry or regulations. I expressly indemnify all parties involved in enrolling in these product(s) from any alleged violations, or threats of litigation, as it relates to the telephone consumer protection act or federal trade commission do not call registry related violations.
I understand I am enrolling in a Health Care Sharing Ministry through Alliance for Shared Health (ASH). A Health Care Sharing Ministry is not health insurance, and this program does not guarantee or promise that my medical bills will be paid. A Health Care Sharing Ministry is a group of individuals who share a common set of ethical or religious beliefs and share medical expenses in accordance with those beliefs.
Alliance for Shared Health is not an insurance company and does not offer insurance products or policies. This program should not be considered as a substitute for an insurance policy. The members of this Health Care Sharing Ministry voluntarily share medical expenses with one another, and ASH coordinates this medical sharing. ASH does not assume any risk for my medical expenses, and ASH makes no promise to pay my medical expenses. I understand I am always liable for my own unpaid medical bills.
ASH manages member sharing contributions by establishing Guidelines that define which medical bills are eligible for sharing. I understand that the Guidelines are not a contract, and nothing presented by ASH constitutes a contract. The Guidelines do not constitute a legally binding agreement, a promise to pay, or an obligation to share. The Guidelines specify what type of expenses are eligible for sharing requests. I acknowledge and understand that ASH reserves the right to exclude sharing eligibility for any pre-existing conditions, whether disclosed at the time of my enrollment or discovered after the effective date of my membership. It is my responsibility to understand which of my medical expenses are eligible for cost sharing, and which medical expenses are not eligible for cost sharing. I acknowledge and understand that preauthorization is required for certain medical expenses.
I agree that I am signing up for a membership program that includes an automatic payment plan. I expressly authorize Shared Health Alliance to automatically debit my bank account or Credit Card on the payment due date provided to collect any and all fees and membership dues for my membership. I acknowledge and agree upon the membership effective date and the payment amount. I also acknowledge and agree that my monthly contributions will be automatically charged or drafted every month from the credit card, debit card or bank account I provided. Further, I attest that I am the holder of the credit card, debit card or bank account provided.
I may cancel automatic payments at any time by calling Member Services at (314) 594-0600. I understand that I may terminate the scheduled payments by providing written notification to the Member Services team five (5) business days prior to the next scheduled payment date. This advance notice allows processing time to ensure the termination occurs prior to the next scheduled payment date. Automatic payment termination cannot be guaranteed with respect to notice provided outside of this window.
I acknowledge and agree that I will receive a “welcome” email within 24 hours of my membership enrollment, which will include my membership information. I have the ability to download all materials, including temporary ID cards, which can then be used until the official cards are received in the mail. It is my responsibility to thoroughly review all materials. Questions can be directed to Member Services at (314) 594-0600.
I consent and agree to the use of electronic signatures of documents. I consent and agree that if I participated in a recorded verification call, my voice consent shall serve as my signature. I agree I am fully responsible for reviewing this application verification and I have reviewed such application carefully to ensure my full understanding of all provisions of the coverage.
By signing below, I agree to receive all documents and correspondence electronically and that I can access the internet, or the email address provided. I understand that I may revoke this authorization or request specific paper documents without revoking this authorization by contacting Shared Health Alliance by mail, email, or telephone.
I agree that, by using this website, my agreement or consent shall be legally binding and enforceable and the legal equivalent of my handwritten or manual signature.
I agree that I have a full and complete understanding of the membership for which I am applying. I certify that I am the applicant listed above.
Alliance for Shared Health acts as a neutral third party to facilitate the need request payments, and may use vendors, at its discretion, to strengthen and support member benefits. ASH has teamed up with Free Market Administrators (FMA) to service the medical sharing needs of the community, distribute payments to providers and to provide sharing summary statements to participants.
Alliance for Shared Health (ASH) Health Share programs are administered by Shared Health Alliance (“SHA”). SHA provides comprehensive administration and management services to agents and associations nationwide.
Cancellation Policy: You may cancel your membership at any time. If your membership is cancelled, you can reinstate your membership by catching up on your giving. However, any medical bills submitted but not yet shared at the time of cancellation—or any medical bills incurred between the time of cancellation and reinstatement—cannot be shared by Alliance for Shared Health. Upon receipt of your cancellation notice, membership for the services/products listed will be terminated to the last day of the month of your membership period. There are no retroactive cancelations or refunds.
Refund Policy: You may only receive a refund provided you have submitted a written notice of cancellation to our office. This notice must be received prior to your membership effective date. No refunds are permitted once membership effective date has commenced. No refunds are permitted if any medical needs have been submitted and shared for any service or product for which you have been enrolled.
Written notification may be sent by email to email@example.com
By clicking the submit button below, I am submitting this application to become an active member of Alliance for Shared Health (ASH) and attest that the participating adult members included herein have read and understand the ASH Statement of Standards. I understand that Alliance for Shared Health is a non-profit health sharing community that seeks to provide a way for its members to access specific medical needs outside of expensive, traditional health insurance. All members must agree with and attest to the statement of standards developed by the Board of ASH. These Statements help ensure our members understand the role ASH membership plays in their health care and promotes a community striving for the good of all members.
Notice: ASH coordinates the sharing of medical expenses is not an insurance company, and neither its guidelines nor plan of operation is an insurance policy. Whether anyone chooses to assist you with your medical bills will be totally voluntary because no other participant will be compelled by law to contribute toward your medical bills. Participation in the organization or a subscription to any of its documents should never be considered to be insurance. Regardless of whether you receive a payment for medical expenses or whether this organization continues to operate, you are always personally responsible for the payment of your own medical bills.
ASH members share a common set of religious and ethical beliefs as it pertains to the above, and in order to participate in ASH, members must attest to the following core beliefs:
I also understand that it's my responsibility to read the ASH Guidelines (http://www.ashcommunity.org/member-guidelines-sha/) and that any medical bills I or my family members submit for sharing will be authorized according to the Guidelines.
Credit Card Policy: Should you decide to pay your monthly fees using a credit card, a 3% fee will be added to the monthly membership fee. Credit card fees are not refundable.
|Standard||1-5 business days||$7.95|
|Two Day||2 business days||$15|
|Next Day||1 business day||$30|
|* Free on orders of $50 or more|