ENROLL NOW

BY COMPLETING THE APPLICATION BELOW

IF YOU ARE READY TO APPLY FOR HEALTH BENEFITS, USE THE FORM BELOW

Please remember to complete all steps of the application before submitting to the membership committee for review.

Once you click submit you should receive an email verification that your application was successfully completed. A member of the HealthShare Connection team will contact you shortly once your application has been approved.

PLAN DETAILS:

If you have questions on plan coverage, click here to see plan comparison and details.

1STEP 1

2STEP 2

3STEP 3

4STEP 4

5STEP 5

6STEP 6

ENROLLMENT: STEP 1

Thank you for your interest in participating in a HealthShare Connections Cost Sharing Plan. Your membership is contingent upon the acknowledgement and agreement of the HSC ethical code, otherwise known as the Member Principals and Responsibilities.

MEMBER PRINCIPALS & REPSONSIBILITIES

The following requirements benefit all members by assuring honor and integrity. Through adherence to these principles, members minimize medical risks and ensure proper accountability while encouraging good health practices. All HSC members must agree with and attest to the following principles. If at any time a member no longer meets all of these membership requirements, they must notify HSC immediately, and their membership and all privileges will cease, unless otherwise indicated:

I understand each of the principles and responsibilities below and, by initialing, indicate my agreement:
- I believe that a community of moral, ethical and health-conscious people can most efficiently and effectively encourage and care for one another by sharing each other’s medical needs directly.
- I understand that HSC is a benevolence organization, not an Insurance Entity, and that while HSC assures that every effort will be made to assure that members fulfill their monthly sharing commitment, HSC in and of itself, cannot guarantee payment of any medical expenses.
- I agree to practice good health measures and strive for a balanced lifestyle.
- I agree to refrain from the usage of any form of illegal substances.
- I understand that medical events caused by, or due to, the act of performing any illegal or unlawful activity will not be shareable.
- I agree to submit to mediation followed by subsequent binding arbitration, if needed, for any instance of a dispute with HSC or it’s affiliates.
NON-SHAREABLE AMOUNT: $1500

I understand that for any submitted medical need (caused by an accident or new illness) there may be a non-shareable portion of the expense that I am required to pay before HealthShare Connection will submit any reimbursements on my behalf. This non-shareable amount will never exceed $1500 per need, but may be lessened by utilizing the copay program made available to you prior to signing this agreement. I understand that I may have unlimited needs throughout the year, and HSC will make every attempt to reimburse my legitimate medical expenses through funds available by membership. I also understand that HSC only requires a non-shareable amount payment on the first three (3) needs for an individual member, or the first five (5) needs for a family membership. Any needs exceeding the first 3 (individual) or 5 (family) needs will not require a non-shareable amount payment from the Primary Member.
PARTICIPATION AGREEMENT

ACCEPTANCE

By initialing below, the Primary Member assumes full-responsibility to notify and inform all persons listed on this application of these principles and responsibilities of membership. Any applicant (or their eligible dependents) who is not comfortable with the HSC Guidelines are free to decline the offer to participate in the HSC Medical Cost Sharing Program.
Signature*
PRINT*
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Date*
MM slash DD slash YYYY

Name and Address
Name*
Social Security Number*
Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Date of Birth*
MM slash DD slash YYYY
HealthShare Connection Sales Representative
PRICING INFORMATION
PLEASE SELECT THE PLAN YOU ARE CHOOSING FOR YOUR 2021 BENEFITS
Plan Type*
* Price shown is monthly price
** Please Note: Applications received after the 15th of the month will be made effective the 1st day of the following month. If you have questions or concerns regarding this application, please call HSC toll free at 1-800-399-1335, and a member of our staff will be happy to assist you.
Plan Cost:
$0.00
TERMS AND ADDITIONS

I have read and understand all of the above, as well as the HealthShare Connection (HSC) Guidelines, and sign below certifying that my answers are true and accurate and indicate my agreement to abide by the Guidelines as well as the Principles & Responsibilities of Membership. If dependents are included in my application, I understand and accept the responsibility to inform each participating dependent of the Principles & Responsibilities of Membership as well as the HealthShare Connection (HSC) Guidelines and accept the responsibility to assure their adherence to, and cooperation with, the requirements of Membership.

Pricing above may be subject to a $75 per month, per member Smoking/Vaping Surcharge. Additionally child dependents on a family plan may be subject to a $50 per member, per month surcharge if they are between the ages of 19-26 and not enrolled in college or a trade school. Verification may be required. All child dependents on a family plan must remain unmarried to continue their benefit plan as a dependent. Child dependents 26 years of age or older will not be eligible for benefits under a family plan.
Signature*
PRINT*
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Date*
MM slash DD slash YYYY

DEMOGRAPHIC, BUILD, AND TOBACCO USE
PRIMARY APPLICANT INFORMATION
Name*
First MI Last
Email
Date of Birth*
MM slash DD slash YYYY
Phone*
Gender*
- M
- F
Tobacco / Vape User?*
- Yes
- No
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
FAMILY & DEPENDENT INFORMATION
MUST BE COMPLETED AND SUBMITTED IN ORDER TO ACTIVATE FAMILY OVERAGE. IF YOU ARE NOT ADDING A SPOUSE OR DEPENDENTS YOU MAY SKIP THIS STEP.
SPOUSE INFORMATION
First MI Last
Email
Date of Birth
MM slash DD slash YYYY
Phone
Gender
- M
- F
Tobacco / Vape User?
- M
- F
CHILDREN INFORMATION: (add only if adding to membership)
Name Date of Birth Social Security # Gender Tobacco / Vape use in the last year
Additional Sharing Restrictions – Tobacco and Vaping

Due to the increased likelihood of higher medical costs associated with tobacco and vaping use, HSC households with one or more tobacco or vape users are required to contribute an additional $75 per month. Unless tobacco or vape users age 50 and older are confirmed tobacco-free for 12 months, they will have a sharing limit of $25,000 for each of the following conditions: 1. Cancer, 2. Heart Conditions, 3. COPD, 4. Stroke.

ADDITIONAL DETAILS

*Please provide additional information for any question marked “yes” on the previous pages that requires further explanation.
Additional Details
QUESTION # NAME OF INDIVIDUAL CONDITION/ DIAGNOSIS DATE OF ONSET DATE LAST TREATED IS TREATMENT COMPLETED?
While member health status has no effect on eligibility for membership, there are limitations on the sharing of events for certain conditions that existed prior to the membership effective date. Medical expenses will not be eligible for sharing during the first two (2) months of membership. Expenses will become shareable during the third month of membership. For additional information, please refer to the Membership Resource Guide.

In general, events that result from a medical condition that existed prior to membership (known or producing observable symptoms) are only fully shareable if the condition appears to be fully cured and thirty-six (36) months have passed without any observable symptoms (either benign or deleterious), treatment, or medication, even if the cause of the symptom is unknown or misdiagnosed. Conditions may be eligible for partial sharing based on the chart below and a full review of the medical history of the member.

Time Constraints For Pre-Existing Conditions After Membership Effective Date	Sharing Eligibility
First 12 months	Not Shareable
Months 13-24	Shareable to $15,000
Months 25-36	Shareable to $30,000
Months 37 and after	Shareable

Authorization*
- I have read and understand all of the above, as well as the HealthShare Connection (HSC) Guidelines, and sign below certifying that my answers are true and accurate and indicate my agreement to abide by the Guidelines as well as the Principles & Responsibilities of Membership. If dependants are included in my application, I understand and accept the responsibility to inform each participating dependent of the Principles & Responsibilities of Membership as well as the HealthShare Connection (HSC) Guidelines and accept the responsibility to assure their adherence to, and cooperation with, the requirements of Membership.
Please Note: Applications received after the 15th of the month will be made effective the 1st day of the following month. If you have questions or concerns regarding this application, please call HSC toll free at 1-888-227-5583, and a member of our staff will be happy to assist you.
Signed
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Date
MM slash DD slash YYYY

ACH AUTHORIZATION FOR CCD TRANSACTIONS:
This Agreement governs ACH transactions Initiated by HealthShare Connection to credit or charge the Company indicated below. Both parties agree to be bound by NACHA Operating Rules as they pertain to all ACH transactions initiated by HealthShare Connection that credit or debit the Company bank account listed below, and acknowledge that the origination of ACH transactions to the listed account must comply with provisions of U.S. law.

This Agreement provides authorization for individual or recurring CCD transactions, to be initiated by HealthShare Connection when individually authorized using the methods designated below. This Agreement will remain in effect until Company cancels it in writing. Both parties agree that this Agreement in conjunction with any of the designated methods constitutes authorization to debit Company’s business bank account or the specified credit card, and Company agrees not to dispute any debits or credits with its bank provided the transaction(s) correspond to the terms indicated in this Agreement.

PLEASE COMPLETE THE INFORMATION BELOW
Bank Name
Name on the Account
Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email
Bank Account Number
Bank Routing Number
Bank City
Bank State
Bank Zip Code
Company Name On Account
ACH Enabled
- This business account is enabled for ACH transactions
Authorization*
- I Authorize HealthShare Connection to initiate ACH Debits and Credits to the bank account indicated above, provided each transaction is initiated according to the terms of this Agreement.
Signature
You may use this signature field or type your full legal name in the field below
Full Name
Title
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Date
MM slash DD slash YYYY
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.

ENROLL NOW

IF YOU ARE READY TO APPLY FOR HEALTH BENEFITS, USE THE FORM BELOW

PLAN DETAILS:

ENROLLMENT: STEP 1

MEMBER PRINCIPALS & REPSONSIBILITIES

NON-SHAREABLE AMOUNT: $1500

Name and Address

PRICING INFORMATION

TERMS AND ADDITIONS

DEMOGRAPHIC, BUILD, AND TOBACCO USE

PRIMARY APPLICANT INFORMATION

FAMILY & DEPENDENT INFORMATION

Additional Sharing Restrictions – Tobacco and Vaping

II. MEDICAL CONDITIONS & TREATMENTS

III. PREGNANCY AND CHILDBIRTH

IV. THIRD PARTY INSURANCE

ADDITIONAL DETAILS

ACH AUTHORIZATION FOR CCD TRANSACTIONS:

Name	Date of Birth	Social Security #	Gender	Tobacco / Vape use in the last year

QUESTION #	NAME OF INDIVIDUAL	CONDITION/ DIAGNOSIS	DATE OF ONSET	DATE LAST TREATED	IS TREATMENT COMPLETED?