Fill - Free fillable 2021 Membership Commitment Form PDF form

2021 Membership Commitment Form

SECTION A

Membership Information

HOUSEHOLD MEMBER

FIRST NAME

LAST NAME

MEMBER ID#

DATE OF BIRTH

All members of the household age 18 and

older must submit this form upon enrollment

in the membership and again within 30 days

of the start of each new year or eligible needs

and medical claims will be placed on hold.

*Network fees are inclusive of, but not limited to

Telemedicine, LifeWorks, Careington Discount Programs,

Zelis and Magellan RX.

SECTION B

Commitment

I, as an: ADULT MEMBER OF THE ALTRUA HEALTHSHARE MEMBERSHIP approve this commitment

of membership.

I understand the Acknowledgements.

I understand that the membership is not insurance but is a voluntary medical needs sharing program,

and that there are no representations, promises, or guarantees that my eligible medical expenses will be

shared. I also understand that sharing for medical needs does not come from an insurance company, but

from the membership according to the Membership Guidelines and Escrow Instructions. To review the

 Membership Guidelines, visit: www.altruahealthshare.org/resources/guidelineswww.altruahealthshare.org/resources/guidelines.

I understand that acceptance into the membership is not an entitlement, but a privilege, based in part on

the medical history information provided on the application. I also understand that any medical condition

that is inquired about but not disclosed on the application—whether meeting the deﬁnition of a pre-existing

condition or not, and discovered after my membership became eective—will be treated as if it had been

disclosed at the time of my enrollment date. I understand that any undisclosed medical conditions will be

processed retroactively back to the eective date of my membership.

I understand that failure to uphold the Commitments and to abide by the Statement of Standards may result

in medical needs becoming ineligible for sharing and this membership becoming inactive.

I understand that the Membership Guidelines in eect on the date of service supersede any spoken or verbal

communication and all previous versions of the Membership Guidelines. I understand that I have access to

the most current version of the Membership Guidelines at: www.altruahealthshare.org/resources/guidelineswww.altruahealthshare.org/resources/guidelines,

I also understand that with notice to the general membership, the Membership Guidelines may change

at any time based on the preferences of the membership and decisions, recommendations, and approval

of the Board of Directors.

I understand that the Membership Guidelines are not a contract and do not constitute a promise or obliga-

tion to share, but instead are for reference of Altrua HealthShare in following the Membership Escrow

Instructions. I also understand that the Membership Guidelines are part of and incorporated into the

Altrua HealthShare application as if appended to it.

I understand that each child must be a dependent to participate in their parent's membership. I also

understand that eligibility for the membership for anyone, a dependent or otherwise, is based on the

Membership Guidelines and that continued payment of monthly contributions does not extend an ineligible

participant's membership.

I understand that monthly contribution amounts are based on, but not limited to, operating costs, which are

inclusive of network fees*, negotiations, medical needs, and the total number of members. I understand

that monthly contribution amounts are calculated on a periodic basis as needed and are subject to change

at any time. I also understand that my monthly contributions are voluntary and that I am not obligated in

any way to contribute to the membership.

This household lives according to each item in the

Statement of Standards.

I/we agree to live a clean and healthy lifestyle and share the following ethical and religious beliefs:

› I believe in caring for one another.

› I believe in keeping my body clean and healthy with proper nutrition.

› I believe the use of tobacco, illicit drugs and excessive alcohol consumption is harmful to the body and soul.

› I believe sexual relations outside the bond of marriage is contrary to the

teachings of the Bible and that marriage should be held in honor.

› I believe abortion is wrong, except in a life-threatening situation to the mother.

› I believe I am obligated to care for my family and physical, mental or emotional

abuse of any kind to a family member or anyone else is morally wrong.

EMAIL ELIGIBILITY@ALTRUAHEALTHSHARE.ORG

PHONE 1.833.325.8782

FAX 512.382.5520

MAIL PO BOX 90849, AUSTIN, TX 78709–0849 PAGE 01/02

I abide by the Commitments.

I have read and understand the Membership Guidelines and accept them as the

governing document for determining eligibility of my, or anyone else's medical

needs submitted to Altrua HealthShare.

I further agree to hold Altrua HealthShare and its directors, ocers, employees,

representatives and service providers harmless, and to limit any dispute I may

have over the eligibility of my, or anyone else's medical needs to the appeal

procedure described in the Membership Guidelines.

So as not to take advantage of fellow members, I have answered all questions

on the Membership Enrollment Application in good faith, truthfully, completely

and accurately.

In recognition of the voluntary nature of the membership, I hereby promise that

in the event of a disagreement over the payment of my or anyone else's medical

needs, my dependents and I will bring no legal claim, demand or suit of any

kind for unpaid medical needs, but will follow the appeal procedure described

in the Membership Guidelines.

I understand that Altrua HealthShare is

not insurance.

I understand that Altrua Ministries (dba Altrua HealthShare) is NOT an insurance

company nor is the membership oered through an insurance company, and

the organization is not subject to the regulatory requirements or consumer

protections of any State Insurance Code.

I issue the following Escrow Instructions to

Altrua HealthShare:

The membership directs Altrua HealthShare, as an escrow agent, to hold the

member-to-member sharing contributions received by Altrua HealthShare,

in an escrow account at an accredited ﬁnancial institution. Those monthly

contributions are then distributed for the purpose of medical needs sharing

on behalf of the members pursuant to the following Escrow Instructions and in

the following order;

To pay the expenses of operating the membership, including all of the

needs necessary for Altrua HealthShare to provide for the continued

viability of the membership;

To share eligible needs pursuant to the Membership Guidelines as

modiﬁed from time to time by Altrua HealthShare, and as interpreted and

applied by Altrua HealthShare;

In the event the membership is to be withdrawn, and after Altrua HealthShare

determines that the funds held in escrow are sucient to pay for the items

listed above, any remaining funds shall be disbursed to qualiﬁed charities,

as determined by Altrua HealthShare.

Altrua HealthShare may deposit or otherwise hold the escrowed contributions

in one or more common bank accounts with escrowed contributions from other

membership participants, until they are distributed pursuant to these instruc-

tions. Altrua HealthShare shall not be obligated to invest the escrowed monthly

contributions, provided; however, that if the escrowed monthly contributions are

invested, Altrua HealthShare shall not be liable for substandard returns or for

losses. Also, as a condition of receiving and distributing the monthly contribu-

tions, Altrua HealthShare will provides a monthly statement to all participants.

That monthly statement is available to be viewed through the member portal.

I verify the above authorizations and acknowledgements and agree to comply to all items in SECTIONS

and B on behalf of myself and all members of the household under the age of  on the membership.

My signature below represents agreement with the  Membership Guidelines and all previous years

Membership Guidelines that apply. I further understand that medical needs are processed by the date

services were rendered and according to the Membership Guidelines in place at that time.

Please Sign

HOUSEHOLD MEMBER SIGNATURE

HOUSEHOLD MEMBER NAME DATE

Please submit this form by email, fax or mail.

ALTRUA MINISTRIES DBA ALTRUA HEALTHSHARE IS NOT AN INSURANCE COMPANY NOR IS THE MEMBERSHIP OFFERED THROUGH AN INSURANCE COMPANY.

MEMBERS ARE SELFPAY PATIENTS. ALTRUA MINISTRIES IS A C NONPROFIT CORPORATION. | DCN  V | ©  ALTRUA HEALTHSHARE

EMAIL ELIGIBILITY@ALTRUAHEALTHSHARE.ORG

PHONE 1.833.325.8782

FAX 512.382.5520

MAIL PO BOX 90849, AUSTIN, TX 78709–0849

2021 MEMBERSHIP COMMITMENT FORM PAGE 02/02

2021 Membership Guidelines

altruahealthshare.org/resources/guidelinesaltruahealthshare.org/resources/guidelines

STATE NOTICES AND DISCLOSURES

ALABAMA CODE TITLE 22-6A-2

Notice: The organization facilitating 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. As such,

participation in the organization or a subscription to any of its documents

should never be considered to be insurance. Regardless of whether you

receive any payment for medical expenses or whether this organization

continues to operate, you are always personally responsible for the

payment of your own medical bills.

ALASKA STATUTE 21.03.021(K)

Notice: The organization coordinating 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.

ARIZONA STATUTE 20-122

Notice: The organization facilitating the sharing of medical expenses

is not an insurance company and the ministry’s guidelines and plan

of operation are not an insurance policy. Whether anyone chooses to

assist you with your medical bills will be completely voluntary because

participants are not compelled by law to contribute toward your medical

bills. Therefore, participation in the ministry or a subscription to any of

its documents should not be considered to be insurance. Regardless of

whether you receive any payment for medical expenses or whether this

ministry continues to operate, you are always personally responsible for

the payment of your own medical bills.

ARKANSAS CODE 23-60-104.2

Notice: The organization facilitating the sharing of medical expenses

is not an insurance company and neither its guidelines nor plan of

operation is an insurance policy. If anyone chooses to assist you with

your medical bills, it will be totally voluntary because participants are not

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 if this organization continues to

operate, you are always personally responsible for the payment of your

own medical bills.

FLORIDA STATUTE 624.1265

Notice: The organization facilitating the sharing of medical expenses

is not an insurance company, and neither its guidelines nor its plan of

operation is an insurance policy. Membership is not oered through an

insurance company, and the organization is not subject to the regulatory

requirements or consumer protections of the Florida Insurance Code.

Whether anyone chooses to assist you with your medical bills will be

totally voluntary because no other participant is compelled by law

to contribute toward your medical bills. As such, participation in the

organization or a subscription to any of its documents should never be

considered to be insurance. Regardless of whether you receive any

payments for medical expenses or whether this organization continues

to operate, you are always personally responsible for the payment of

your own medical bills.

GEORGIA STATUTE 33-1-20