• America's HealthShare: Add a Member to Your Membership

    Please provide all of the detailed information for each person you would like added to your America's HealthShare membership.

  • Thank you for helping the America's HealthShare community to grow!

    Use this form to add a Member to your existing America's HealthShare Membership.

    Please note that any new Member added to the Membership must complete a medical history questionnaire. If you need additional time to gather the necessary details, you are able to save your progess and return at a later time. At the bottom of each page of the application, there is a button to "Save." If you decide to use this feature, you have 30 days to return to complete your form and must use the link provided to retrieve your progress

    At the very end of the form, you will be required to electronically sign your questionnaire.

    Adding a Member to your Membership may result in an increase to your Monthly Contribution. If you have any questions about this or adding a Member to your Membership, please contact us at support@americashealthshare.org

  • Add a Member Selection

    Please choose which version of the Add a Member Medical History Questionnaire form you need to fill out.

  • Existing Membership Information

    Help us find the right existing membership to add this new Member. Please provide information about the Primary Member on your existing America's HealthShare Membership.
  • Primary Member: Date of Birth*
     / /

  •

  • New Member Information

    Please provide the following information for the new Member you wish to add to your Membership.
  • Gender*
  • Date of Birth*
     / /
  • Is this new Member a Spouse or a Dependent?*
  • HIDDEN: Age Calculator – DO NOT TOUCH
     / /
  • Requested Effective Date (must be 1st of month and within the next 3 months)*
     / /
  • Does the Member have the same physical address as the Primary?*

  • Same Home Phone as Primary?*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Adult Dependent

    America's HealthShare allows adult dependents to join their parent's or guardian's Membership provided certain requirements are met.

  • Adult Dependent Eligibility

    We show that your answers and selections result in the Dependent Applicant being at least twenty years old.

    Based on the above, we have determined your Dependent may require additional Medical Review to determine their eligibility on your America's HealthShare Membership.

  • Please select your Adult Dependent's reason for eligibility*

  • Learn More about Dependents

    To learn more about the types of Dependents allowed on your Membership, see the America's HealthShare Sharing Guideliens. 

  • Other Healthcare Coverage

    Add information for any additional healthcare coverage for the new Member
  • Does the Member currently have any additional healthcare coverage? Select all that apply.*
  • Coverage Start Date*
     / /
  • Are you planning to continue this coverage while a Member of America's HealthShare?*
  • Medicare Start Date*
     / /

  • Medical History Questionnaire

    Please answer the following general health questions
  • Have you used nicotine or tobacco products (cigarettes or vaping) in the past 5 years*
  • How many times do you use nicotine or tobacco per year?*
  • Have you ever been diagnosed with any of the following conditions? (select all that apply)*
  • Have you ever had a health condition that needed regular treatment, medicine, or follow-up care? (Examples: cancer, heart disease, lung disease, etc.)
  • Are you currently taking, or have you been prescribed in the last 24 months, any medication, supplements, and/or medical equipment? (This includes pills, creams, injections, liquids, inhalers, pumps, etc.)
  • Within the past 24 months, have you seen a healthcare provider(s) for any reason other than routine wellness or cold/flu symptoms?
  • Have you ever had any surgeries or hospitalizations?
  • Are you currently pregnant?
  • Date of your last menstrual period*
     / /
  • Expected Due Date*
     / /
  • Do you have any other conditions that you think we should know about?

  • America Well

  • Based upon our shared belief that we all have a moral and spiritual obligation to care for our bodies, America Well was created so that America’s HealthShare could enroll those who have chronic conditions that are particularly responsive to lifestyle changes. These Members are able to participate in our medical cost sharing ministry while improving conditions such as diabetes, hypertension, heart disease, high cholesterol, obesity, and addiction to cigarettes. America Well assists Members in making lifestyle changes that foster better health and reduce the prospect of progressive disease.

    America Well participants are assigned a health coach. The coach assists them in developing personal goals, tracking progress, and reaching their health-related goals. If a Member has been identified as having one of the below conditions at the time of enrollment, expenses related to that condition will not be shared unless they enroll in America Well. A participant fee of $80 per month is assessed in addition to the Monthly Contribution Amount while the Member demonstrates progress and until their personal goals are met.

  • Possible Conditions for Enrollment

    We show that you answered 'Yes' to at least one of the following conditions:

    • Diabetes
    • High Blood Pressure
    • High Cholestorol
    • Osteoperosis
    • Nicotine/Tobacco Use
    • Possible Obesity (height and weight calculation of a BMI result outside the recommended guidelines)

    Based on some of your answers, we have determined you may require additional Medical Review to determine your eligibility for the America Well program. Our team will reach out to if more information is needed.

  • Learn More about America Well

    To learn more about the America Well program and what you can expect when discussing with our Onboarding and Enrollments team: Learn More

  • Membership Acknowledgments

    You will be required to electronically sign this application prior to submission. Please read the following statements carefully.

  • PROGRAM, NOT INSURANCE. I acknowledge that I am enrolling in America’s HealthShare a healthcare sharing ministry of Melita Sharing Ministry that is voluntary and cooperative and not insurance. I have read and understand any disclaimer to this effect and understand that there are no representations, promises or guarantees that my medical expenses will be paid. I also understand that any funds that I may receive for medical expenses do not come from an insurance plan but are voluntary donations by the members.

    SIXTY-DAY WAIT. I acknowledge that for sixty (60) days after enrollment and acceptance as a Sharing Member, medical expenses for any reason, other than accident, emergencies, and acute illness, are not eligible for sharing among members.

    CHANGES TO SHARING GUIDELINES. I acknowledge that amendments to the Guidelines will take effect as soon as is administratively practical or as designated by the Board of Directors. Dates of Service of medical expenses submitted for sharing will be subject to the edition of the Guidelines in effect when recorded as received by America’s HealthShare and supersedes all other editions of the Guidelines and any other communications, written or verbal.

    CALCULATIONS OF SUGGESTED MONTHLY CONTRIBUTION. acknowledge that the suggested Monthly Contribution is calculated on the total number of healthcare sharing ministry members, the amount of medical expenses submitted for sharing, and the administrative cost of operating the healthcare sharing ministry program. I further acknowledge that the suggested Monthly Contribution is calculated on a periodic basis as needed and is subject to change. I understand that the donation of the Suggested Monthly Share Amount is voluntary and that I am not obligated to send any money.

    ACCOUNT FEE. America’s HealthShare account service fee is for the costs of processing the Monthly Contribution and can be discounted if the member uses Automated Clearing House (ACH) for the Monthly Contribution.

    OPTIONAL COMMUNICATION BETWEEN MEMBERS. I acknowledge that America’s HealthShare’s cost sharing technology also enables members to send one another notes of encouragement or prayer and, upon activation, that each member can choose how to be identified in this system or to remain anonymous.

    APPLICATION ACCEPTANCE. I acknowledge that America’s HealthShare, pursuant to the Sharing Guidelines, has the discretion to accept, reject, or modify my membership. I will not assume that my application has been accepted until I have received a written confirmation from America’s HealthShare.

    MEDICAL HISTORY QUESTIONNAIRE. I acknowledge that I will submit a full and complete Medical History Questionnaire (MHQ) for all individuals on this application upon becoming a member of America’s HealthShare.

    I understand that the America’s HealthShare team will review the MHQ for each individual and will contact me with any questions or requests for clarification. 

    I acknowledge that eligibility for sharing is based on the information provided in the MHQ, and that any medical conditions not disclosed may be ineligible for sharing. If the MHQ is not submitted or is incomplete, any related conditions may also be considered ineligible for sharing.

    I understand that pre-existing conditions are evaluated according to the categories outlined in the America’s HealthShare Sharing Guidelines.

    I also acknowledge that I had the opportunity to request, complete, and submit a MHQ prior to becoming a member in order to understand which pre-existing conditions may or may not be eligible for sharing. 

    ACCEPTANCE OF GUIDELINES. I have read and understand the Sharing Guidelines and accept them as the guiding document for all interactions among members and for determining the eligibility of medical expenses that I may submit for sharing. If a difference of opinion should arise as to the use, application or interpretation of those Sharing Guidelines, I will follow the appeal process outlined in the Sharing Guidelines for the resolution of any or all disputes. I acknowledge that I will treat all America’s HealthShare employees and representatives with mutual kindness and respect as taught by the Gospel of John 13:34 "I give you a new commandment: love one another. As I have loved you, so you also should love one another."

    PAYMENT OF MEDICAL NEEDS. I acknowledge that any medical need shared will be used for the sole purpose for which it was shared.

  • Protected Health Information

    You will be required to electronically sign this application prior to submission. Please read the following statement carefully.

  • You will be required to electronically sign this application prior to submission. Please read the following statements carefully. America’s HealthShare may request and may receive from me and my healthcare providers health information prior to my enrollment in America’s HealthShare if a completed Medical History Questionnaire is provided. America’s HealthShare will protect the confidentiality of that information in the same manner as all other health information America’s HealthShare maintains and, if I do not enroll, America’s HealthShare will not use or disclose the information America’s HealthShare obtained for any other purpose.

    America’s HealthShare will make disclosures of my health information as necessary for my treatment. A doctor or health facility involved in my care may request some of my health information that America’s HealthShare holds in order to make decisions about my care. America’s HealthShare will use and disclose my health information as necessary for payment purposes. For instance, America’s HealthShare may use information regarding my medical procedures and treatment to process and arrange for the payment of medical bills, to determine whether services are medically appropriate or to otherwise pre authorize or certify services as eligible to be shared under the Guidelines.

    America’s HealthShare may also forward such information to another health plan that may also have an obligation to process and pay expenses on my behalf. America’s HealthShare will use and disclose my health information as necessary for healthcare operations which include peer review, business management, accreditation and licensing, utilization review and management, quality improvement and assurance, enrollment, voluntary disclosure of health conditions, compliance, auditing, and other functions related to my healthcare management. America’s HealthShare may also disclosure my health information to another healthcare facility, healthcare professional, or health plan for such things as quality assurance and case management, but only if that facility, professional, or plan also has or had a patient relationship with me.

    America’s HealthShare may from time to time disclose my health information to family, friends, and others who are involved in my care or in payment for my care in order to facilitate that person's involvement in caring for me or paying for my care. If I am unavailable, incapacitated, or facing an emergency medical situation and America’s HealthShare determines that a limited disclosure may be in my best interest, America’s HealthShare may share limited health information with such individuals without my approval. America’s HealthShare may also disclose health information to an entity that is authorized to assist in disaster relief efforts in order for that entity to locate a family member or other persons that may be involved in some aspect of caring for me.

    Certain aspects and components of America’s HealthShare services are performed through contracts with outside persons or organizations such as legal services, Utilization Management Services, Preferred Provider Organizations, Pharmacy Benefit Managers, etc. At times it may be necessary for America’s HealthShare to provide some of my health information to one or more of these outside persons or organizations who assist with healthcare operations.

    America’s HealthShare may communicate with me regarding my medical expenses, share amount, or other matters related to my health.

    America’s HealthShare may, from time to time, use my health information to determine whether I might be interested in or benefit from treatment alternatives or other health-related programs, products or services which may be available to me as a member. 

    America’s HealthShare may use my health information to identify whether I have a particular illness, and contact me to advise me that, as a member, a disease management and/or wellness program may help me manage my illness or health condition. 

  • Review & Agreement

    Please review your following selections to confirm their accuracy. You will be required to agree to this Medical History's selections and information by electronically signing prior to submission.

  • Primary Member Information

  • Membership ID  {applicantExistingMembershipID}
    Primary Name {applicantExistingPrimaryMembershipName} 
    Date of Birth:  {applicantDOB}
    Email on Record:  {applicantExistingPrimaryMembershipEmail}

  • New Member Information

  • Member Name: {applicantName}
    Gender: {applicantGender}
    Age: {hiddenApplicantCurrentAge}
    Spouse or Dependent? {addedMemberSpouseOrDependent}
    Adult Dependent? {applicantAdultDependentAcknowledgment}{hiddenAdultDependentNoAnswerField}
       
    Additional Coverage? {applicantCOBSelection}
    Insurance Provider: {applicantCOBHealthInsurance} | {applicantCOBPolicyNumber} | {applicantCOBCoverageStartDate}
    Medicare: {applicantCOBMedicarePlanNumber} | {applicantCOBMedicareStartDate}

    Continuing Coverage?

    		 {applicantCOBPlanningToContinue}

  • New Member Medical History

     

    Height:   {applicantHeight} inches Weight:  {applicantWeight} lbs

     

    QUESTION   ANSWER
    Have you used nicotine or tobacco products (cigarettes or vaping) in the past 5 years?   {applicantProviderin24MonthsAnswer}
    Have you ever been diagnosed with diabetes, high blood pressure, high cholesterol, or osteoporosis?   {haveYou} 
    Have you ever had a health condition that needed regular treatment, medicine, or follow-up care?    {haveYou1285}
    Are you currently taking, or have you been prescribed in the last 24 months, any medication, supplements, and/or medical equipment?    {areYou}
    Within the past 24 months, have you seen a healthcare provider(s) for any reason other than routine wellness or cold/flu symptoms?    {withinThe}
    Have you ever had any surgeries or hospitalizations?    {haveYou1291}
    Are you currently pregnant?    {areYou1293}
    Do you have any other conditions that you think we should know about?   {doYou} 

     

  • Final Agreement & Signature

  • By signing below, I acknowledge that I have read this entire agreement in full and agree to comply with the above polices and guidelines of America's HealthShare and acknowledge that I understand all terms, language, and concepts herein.

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