Alive & Well Enrollment Form

Name* This field is required.

First Name

Last Name

Your Age* This field is required.

Have you had signs, symptoms, or a diagnosis of any these or other major medical needs?:* This field is required.Select all that apply. Please describe additional health history under "Other."

Cancer treated in the last three years

Heart Disease treated in the last three years

Stroke treated in the last three years

Chronic medical conditions treated in the last three years

Insulin-dependent diabetes

Currently pregnant

I have no history of major medical health problems or conditions. (List any others below.)

Other

Have you had any surgeries in the past five years?

YESNO

Please list the type(s) of surgery and date(s).

Have any immediate family members registering with you experienced signs, symptoms, or a diagnosis of these or any major medical needs?:* This field is required.Eligible family members my include: legally married spouses and/or unmarried children under age 26. Select all that apply. Please describe additional health history under "Other."

Cancer treated in the last three years

Heart Disease treated in the last three years

Stroke treated in the last three years

Chronic medical conditions treated in the last three years

Insulin-dependent diabetes

Currently pregnant (spouse)

I do not have immediate family members with a history of major medical health problems or conditions. (List any others below.)

Other

Congrats on your baby on the way! Please review the guidelines below.* This field is required.Maternity Needs may only be Sharable if conception occurs 90 days or longer after the applicable Member’s Effective Date. The member will be responsible for two IUA’s, one for mom and one for the baby. Eligible Medical Needs related to prenatal, birth and postnatal needs may be Shareable up to $17,000.00 for normal vaginal delivery and $20,000.00 for cesarean delivery.

What health conditions, problems, or concerns do you currently have?* This field is required.

Have any immediate family members who are enrolling with you had any surgeries in the past five years?

YESNO

Please list the type(s) of surgery and date(s).

What conditions, problems, or concerns to your family members have? (Speaking of immediate family members who are registering with you.) Eligible family members my include: legally married spouses and/or unmarried children under age 26.

Do you or any family members registering with you use medications for chronic medical conditions (such as insulin or blood thinners)?* This field is required.

YESNO

Please provide the name, dosage, and purpose of you or your family member's medications for chronic medical conditions (such as insulin or blood thinners)?* This field is required.This information will help us inform you whether the community is able to share in these medication costs. We may also be able to provide recommendations on resources for affordable prescriptions.

Please review the Big Stuff Health Share guidelines on prescription medications.* This field is required.Only medications required to treat an Eligible Medical Need may be Shareable for a period of up to 3 months. All other medications are not Shareable.

Why are you interested in joining Big Stuff Health Share?* This field is required.Mark all that apply to you. Please list any other reasons under "Other."

I want to lower the costs of paying for my healthcare.

I want to be part of a community that will support me when I need it.

I love the concept and model of a health share.

Big Stuff Health Share will offers more liberty in my medical choices.

Other

The Big Stuff Health Share community shares up to $1 million in medical expenses per membership. On a scale of 1 to 5, how comfortable are you with this shareable amount?* This field is required.

We seek community members who are *grateful* to save money on medical care and help others in times of need. On a scale of 1-5, how grateful would you be to join the Big Stuff Health Share community?* This field is required.

We would love to help you save and put away at least $10,000 in your personal savings for future medical costs for you and your family. Do you believe you can achieve this goal?* This field is required.

YESNO

We partner with licensed medical providers to offer guidance on the "big stuff." They pre-approve non-emergency medical treatment before our community shares in the costs. Do you agree to contact our medical team before requesting health share funds?* This field is required.

YESNO

Here a few of our Foundations for Membership. Do you agree with these?* This field is required.- I agree that a community of moral, ethical and health-conscious people can most efficiently and effectively encourage and care for one another by directly sharing the costs and expenses associated with each other’s health care needs. - I agree to practice good health measures and strive for a balanced lifestyle. - I agree to refrain from the usage of any form of illicit/illegal drugs and excessive alcohol consumption, all of which are harmful to the body. I understand that tobacco consumers have an increased share of $50 monthly per household. - I believe I am obligated to care for my family and that physical, mental or emotional abuse of any kind to a family Member or anyone else is morally wrong.

How did you find out about Big Stuff Health Share?We're so glad you did!

Online search

My primary care provider (or family doctor)

A current member of Big Stuff Health Share

A referral or word of mouth

Alive & Well