Archive | March, 2018

Medishare

23 Mar

 

Forms Center

Start, Complete, and View your Medi-Share Forms

Print Form    Save as PDF Back to Forms Center

Application Review Report

Name: Thomas Doody CCM ID#: 119298243 Date Submitted: 03/23/2018

Welcome to Medi-Share

This Application Review Report is based on the medical information you provided during your application process. It includes information regarding your pre-existing medical conditions and the applicable Medi-Share Guidelines.

 

If from your medical history we identified any pre-existing conditions that are ineligible for sharing at this time based on the Medi-Share Guidelines, they will be listed in the Review Results section below.

If any changes are made to this report during your application process, you will be notified via your Forms Center to sign the new report.

Any additional pre-existing medical conditions that come to our attention during the remainder of the application process or during your membership may not be eligible for sharing either, based on the Medi-Share Guidelines.

Read Medi-Share Guidelines, Section VI. Part F. Pre-Existing Medical Conditions or Related Conditions.

 

Please carefully review the following sections of the Medi-Share Guidelines for a complete list of all other medical conditions and services that are not eligible for sharing or are subject to limited sharing:

     Section VI. Part I. Medical Conditions and Services Subject to Limited Sharing

     Section VI. Part J. Medical Conditions and Services Not Eligible for Sharing

 

By signing this Application Review Report and completing any remaining steps to your application process, you agree that you have provided Medi-Share with all medical history on the Medical Questionnaire and that you understand the conditions and items that are not eligible for sharing according to the Medi-Share Guidelines (links are provided above, and the complete Medi-Share Guidelines can be viewed online at http://www.mychristiancare.org).

 

Medi-Share Guidelines, Section II. Part C. Application Review

Applicants provide medical and lifestyle information during the application process. This helps determine qualification for Medi-Share membership. It may be necessary for applicants to have providers submit medical records.

 

If a Member or Applicant becomes aware of any medical history not reported during the application process, that information should be immediately submitted in writing to CCM. If information that would disqualify them from membership is omitted, medical bills may not be shared and/or membership may be cancelled.

 

Medi-Share Guidelines, Section II. Part D. Health Partners

You may be required to participate in a Health Partnership or Health Partnership Disease Reversal program if you are at higher risk for disease based on reported measurements and/or medical history. Read more about that here.

 

Again, please carefully review the following parts of Medi-Share Guidelines Section VI. regarding Details of Sharing:

     Section VI. Part F. Pre-Existing Medical Conditions or Related Conditions

     Section VI. Part I. Medical Conditions and Services Subject to Limited Sharing

     Section VI. Part J. Medical Conditions and Services Not Eligible for Sharing

Signature

Agreement terms and conditions accepted and signed by Thomas Doody.

Need help? Talk to one of our representatives by calling (800) 772-5623.

 

Copyright 2017 © Christian Care Ministry – All Rights Reserved.

.

 

medishare

23 Mar

 

Forms Center

Start, Complete, and View your Medi-Share Forms

Print Form    Back to Forms Center

Medical Questionnaire

Name: Thomas Doody CCM ID#: 119298243 Date Submitted: 03/23/2018

Do you (or your dependents applying) currently use or have a history of using tobacco, electronic nicotine delivery systems (e-cigarettes or vapes), or waterpipe tobacco systems in the last 12 months? No

Have you (or your dependents applying) used illegal substances (defined as illegal on the federal level, including marijuana) or abused legal drugs in the last 12 months? No

Do you (or your dependents applying) have a history of (or treatment/medication for) problems with veins and/or arteries (chronic blood vessel disease)? (TIA, Stroke, Aortic Aneurysm, Carotid Artery Stenosis, Renal Artery Stenosis, Diseases of Arteries, Arterioles & Capillaries, Varicose Veins, Cerebrovascular Disease, DVT, or other) No

Do you (or your dependents applying) have a history of (or treatment/medication for) a heart problem or condition? (Heart damage or disease related to Rheumatic Fever, Irregular Heartbeat, Hypertensive Heart Disease, Coronary Heart Disease, Pulmonary Heart Disease, Pericarditis, Myocarditis, Endocarditis, Heart Block, Tachycardia, Bradycardia, Pacemaker, Defibrillator, Any Heart Surgeries, or other heart-related issue(s)) No

In the last 36 months, have you (or your dependents applying) had a history of (or treatment/medication for) a disease in any organ excluding the heart? (Kidney, Lung, Liver, or Gastrointestinal/Diverticulitis) No

In the last 36 months, have you (or your dependents applying) had a history of (or treatment/medication for) a degenerative or chronic neurologic condition? (Parkinson’s, Multiple Sclerosis, Dementia, Alzheimer’s, Epilepsy/seizures, ALS, or Muscular Dystrophy) No

In the last 36 months, have you (or your dependents applying) had a history of (or treatment/medication for) conditions affecting the spine, hips, shoulders, neck, or knees? No

In the last 36 months, have you (or your dependents applying) had joint replacement or surgery of the spine, hips, shoulders, neck, or knees? No

In the last 36 months, have you (or your dependents applying) had a history of (or treatment/medication for) a chronic infectious condition? (Hepatitis B/C, Lyme Disease, Sicca, Stiff Man, or Guillain-Barre Syndrome) No

In the last 36 months, have you (or your dependents applying) had any form of cancer?

 

Please let us know what type of cancer you have experienced below. THE FOLLOWING CONDITIONS DO NOT NEED TO BE REPORTED: basal or squamous cell carcinoma/skin cancer No

Do you (or your dependents applying) have a history of diabetes (not gestational diabetes), pre-diabetes, insulin resistance, hypoglycemia, metabolic syndrome, fatty liver, and/or hyperglycemia? No

In the last 36 months, have you (or your dependents applying) had a history of a chronic inflammatory condition? (Lupus, Rheumatoid Arthritis, Inflammatory Bowel Disease, Gout, Crohn’s Disease, Ulcerative Colitis, or other) No

In the last 36 months, have you (or your dependents applying) had a history of high cholesterol and/or high triglycerides? No

In the last 36 months, have you (or your dependents applying) taken medication for high cholesterol and/or high triglycerides? No

In the last 36 months, have you (or your dependents applying) had a history of high blood pressure and/or hypertension? No

In the last 36 months, have you (or your dependents applying) taken medication for high blood pressure and/or hypertension? No

In the last 36 months, have you (or your dependents applying) been a transplant recipient or provided material for a transplant? No

In the last 36 months, have you (or your dependents applying) had a history of surgical intervention that resulted in loss of limb/organ? (ostomy complications, prosthetic or amputation complications, implants and/or devices) No

In the last 36 months, have you (or your dependents applying) had a chronic disorder of the pituitary gland? No

In the last 36 months, have you (or your dependents applying) had a history of (or treatment/medication for) a chronic respiratory disorder? (Asthma, Sleep Apnea, COPD, Emphysema, or other) No

Have you (or your dependents applying) had surgery for weight loss? No

In the last 36 months, have you (or your dependents applying) had a history of (or treatment/medication for) gallstones, kidney stones, endometriosis, or uterine fibroids? No

Do you (or your dependents applying) have a history of (or treatment/medication for) chronic disease/illness not already indicated in this questionnaire that may require surgical intervention in the next 12 months? (hernia, sinus and/or ear surgeries) No

Are you (or any of your dependents applying) currently pregnant?

 

Please Note: If you are pregnant when you join Medi-Share (even if you are not yet aware), your maternity will not be eligible for sharing. You must be a member from the month of conception through the month of delivery for your maternity to be eligible for sharing according to the Medi-Share Guidelines, Section VII. A. No

Bills related to the following chronic, genetic or congenital conditions will not be eligible for sharing for the first 36 months of membership. I Understand

Need help? Talk to one of our representatives by calling (800) 772-5623.

 

Copyright 2017 © Christian Care Ministry – All Rights Reserved

medishare

22 Mar

 

Forms Center

Start, Complete, and View your Medi-Share Forms

Print Form    Save as PDF Back to Forms Center

Acknowledgement

Name: Thomas Doody CCM ID#: 119298243 Date Submitted: 03/22/2018

How did you apply?

A representative helped me

My representative has explained, and I understand, that Medi-Share is not insurance and that CCM does not guarantee payment of any of my medical bills.

I agree

My representative explained, and I understand, that no other Medi-Share member, nor CCM, has any legal obligation to contribute to the payment of my medical bills.

I agree

My representative explained, and I understand, that other Medi-Share members selected to share in the payment of my medical bills are notified that their monthly shares will be used to assist me.

I agree

Need help? Talk to one of our representatives by calling (800) 772-5623.

 

Copyright 2017 © Christian Care Ministry – All Rights Reserved.

 

medishare

22 Mar

 

Forms Center

Start, Complete, and View your Medi-Share Forms

Print Form    Save as PDF Back to Forms Center

Testimony & Commitment

Name: Thomas Doody CCM ID#: 119298243 Date Submitted: 03/22/2018

Do you agree with our Statement of Faith below (Medi-Share Guidelines, Section II.A.) ?

All adult members (18 years of age or older) must have a verifiable Christian testimony indicating a personal relationship with the Lord Jesus Christ and profess to the following Statement of Faith:

 

I believe that there is only one God (Deuteronomy 6:4) eternally existing in three Persons: the Father, Jesus Christ the Son, and the Holy Spirit (Matthew 28:19). I believe Jesus is God, in equal standing with the Father and the Holy Spirit (Colossians 1:15-20, 2:9).

I believe the Bible is God’s written revelation to man and is verbally inspired, authoritative, and without error (2 Timothy 3:16-17).

I believe in the deity of Jesus Christ — who existed as God before anything was created (John 1:1), His virgin birth (Matthew 1:23), sinless life (Hebrews 4:15), miracles, death on the cross to provide for our redemption (1 Peter 2:24), bodily resurrection and ascension into heaven (1 Corinthians 15:3-8), present ministry of intercession for us (Hebrews 7:24-25) and His return to earth in power and glory (Matthew 24:30). He is the world’s only Savior and is the Lord of all (John 14:6, Acts 4:12, Isaiah 45:21-23).

I believe in the personality and deity of the Holy Spirit (Acts 5:3-4), that He performs the miracle of new birth in an unbeliever and indwells believers (1 Corinthians 3:16), enabling them to live a godly life (Romans 8:14).

I believe man was created in the image of God, but because of sin was alienated from God. Alienation can be removed only by accepting God’s gift of salvation by grace through faith (Ephesians 2:8-10) which was made possible by Christ’s death and resurrection. This faith will be evidenced by the works that we do (James 2:17, 26).

I agree

Do you agree with the following?

That sin has separated man from God.

That the Bible teaches that all have sinned and come short of the glory of God.

That our sin is forgiven only through faith in Christ and his atonement for our sin.

By believing in Christ and his atonement we are forgiven from all our sin.

Our relationship with the Lord is because of His grace and mercy.

The belief in Jesus Christ is the only way to salvation and eternity in heaven.

That the evidence of our faith in Christ will be seen by changed life and works that glorify the Father.

Yes

Do you have a personal relationship with Jesus Christ?

Yes

Do you have a place where you are consistently being taught the Bible?

Yes

What is your denomination?

Catholic

Affordable Care Act Acknowledgement

I understand that compliance with the Affordable Care Act requires that I must either be an active member of a health care sharing ministry or have purchased a qualified health plan. I understand that I can only purchase a qualified health plan during an open enrollment period. I understand that if I stop my Medi-Share participation for whatever reason, including voluntarily or if my participation is placed in inactive status due to a failure to share or follow the Medi-Share Guidelines, that I will not be in compliance with the Affordable Care Act.

 

If my participation in Medi-Share ends outside of the open enrollment period and I am not able to purchase a qualified health plan, I understand that I will be subject to the law’s penalty for each month that I am not either enrolled in a qualified health plan or am a member of a health care sharing ministry. I also understand that the same penalties shall apply to anyone in my family who participates in Medi-Share through my membership who is also required to either be enrolled in a qualified health plan or be a member of a health care sharing ministry.

 

I Understand

Authorization for Release of Protected Health Information

  1. I authorize the disclosure of protected health information, including but not limited to, medical records, reports, medical bills, pharmaceutical records, diagnostic test results, and lab test results.

 

  1. I understand that the following parties will receive this information regarding my membership in the sharing program: Christian Care Ministry, Inc. (“CCM”), its employees and authorized agents.

 

  1. Those parties that receive protected health information may disclose it for purposes of treatment, payment, or operations of Medi-Share. They may otherwise disclose information only as allowed or authorized by law. These parties include insurers to which proposed member has applied or may apply, pharmacy benefit managers, physicians, hospitals, clinics or other medical related facilities, health care clearing houses or persons who perform tasks for them.

 

  1. I understand that this protected health information is needed to verify eligibility of my bills submitted to CCM.

 

  1. Unless revoked earlier, this authorization will be valid as long as I am enrolled in Medi‐Share plus 18 months from the date my membership ends.

 

  1. I understand that I may revoke this authorization at any time by notifying CCM in writing at P.O. Box 120099, West Melbourne, FL 32912, but if I do, it won’t have any effect on any actions taken prior to receiving the revocation.

 

  1. I understand that this authorization is voluntary; I understand that I may get a copy of this form after signing it.

 

  1. I understand that if an organization I authorize to receive the protected health information is not a health plan or healthcare provider, federal or state law may no longer protect the released information and it will no longer be private.

 

I Understand and Agree

By joining Medi-Share, I understand and agree to the following:

  1. I have carefully read and commit to abide by all provisions stated in the Medi-Share Guidelines. All persons listed on this form believe that the body is the temple of the Holy Spirit, to be kept pure and as such:

 

I do not engage in sex outside of traditional Biblical marriage, which is a union of one man and one woman. (Gen.2:22-24, Mat. 19:5, Eph. 5:22-32)

I do not and will not use tobacco in any form or illegal drugs and have not for the last 12 months.

I agree not to abuse legal drugs, including alcohol and have not abused them for the past 12 months.

I understand that when any member of the family chooses not to live by these principles, I have a responsibility to notify CCM. I also realize the family member may no longer qualify to participate in Medi- Share and their membership will be cancelled and his or her bills will not be eligible for sharing.

  1. I understand that Christian Care Ministry, Inc. (CCM) matches a Medi-Share member’s medical bills with other members who have volunteered, in faith, to share in meeting needs through the biblical concept of Christian mutual sharing. I realize and accept that all money comes from the voluntary giving of Medi-Share members, not from CCM, and that CCM does not pay nor is it liable for the payment of any medical bills.

 

  1. Each month I will be notified in advance of the fellow Christian who will be receiving my gift toward their medical bills. I will endeavor to pray for and encourage this member in writing. Similarly, I understand that when I have a medical bill published for sharing, my information, including email and/or mailing address, will be available online on the secure member website for fellow members to pray for and encourage me.

 

  1. I understand that in order to determine the eligibility of the medical bills for sharing when an illness or injury occurs, medical records may be required from providers who have diagnosed or treated the member. I understand and agree that no medical bill will be shared if authorization for obtaining such medical records is withheld.

 

  1. I consent to the recording of all telephone calls to or from CCM.

 

  1. I agree that in cases where all administrative appeals have been exhausted and after an appeal process, any and all remaining disputes will be settled solely as follows: by biblically-based mediation, not in a secular court. If resolution of the dispute and reconciliation does not result from mediation, the matter shall then be submitted to an independent and objective arbitrator for binding arbitration. I agree that suing fellow Christians, including Christian ministries, is contrary to scripture (1Cor. 6:1-8); therefore, I will bring no suit, legal claim or demand of any sort against CCM in the civil court system, with the sole exception of enforcing any favorable arbitration award or mediated agreement.

 

  1. I understand that any false statements on or omissions from this form, the Application for the Medi-Share Program or at any time during my participation in Medi-Share will be cause for cancellation of my Medi-Share membership. I understand that there is limited sharing during the first month of membership.

 

I Understand and Agree

If I am accepted into the Medi-Share program my one-time Medi-Share fee of $120 will be due with my first month’s share. This does not apply to Senior Assist, Add-On or an applicant leaving family membership for individual membership. A one-time fee of $2 will also be due for my ACCU membership fee, unless I am an Add-On applicant.

I Understand and Agree

Signature

I declare that the information contained herein is complete and true to the best of my knowledge.

Agreement terms and conditions accepted and signed by Thomas Doody.

Need help? Talk to one of our representatives by calling (800) 772-5623.

 

Copyright 2017 © Christian Care Ministry – All Rights Reserved.