HealthShare Works

Principles & Responsibilities

HIPAA Authorization

 

Thank you for your interest in joining HealthShare Works.  HSW works with Zion HealthShare and follows Zion’s  Member Guidelines.

 

Please scroll though conditions below before checking box

 

Payment Authorization Terms & Conditions

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify SHMI Inc. in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. For ACH debits to my checking/savings account, I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an ACH transaction being rejected for Non Sufficient Funds (NSF) I understand that SHMI Inc. may at its discretion attempt to process the charge again within 30 days, and agree to an additional charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this credit card/bank account and will not dispute these scheduled transactions with my bank or credit card company; so long as the transactions correspond to the terms indicated in this authorization form.

While member health status has no effect on eligibility for membership, there are limitations on the sharing of needs for certain conditions that existed prior to the membership effective date. Needs that do not qualify for medical sharing may still be met in part or in whole through Special Needs Sharing. (See Zion Health Guidelines for a detailed list of shareable and non-shareable needs.)

In general, needs that result from a medical condition that existed prior to membership (known or producing observable symptoms) are only 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 symptoms is unknown or misdiagnosed. Additional limitations apply for specific medical conditions as indicated below. See Zion Health Guidelines.

Medications prescribed for chronic, long-term conditions and taken on a regular, recurring basis (i.e. maintenance medications) are not shareable unless associated with a new diagnosis and then only for 120 days. Examples of common maintenance medications are insulin, blood pressure medicine, cholesterol medicine, etc.

Please be advised:

Medical expenses for child birth with an expected delivery date within the first 12 months of membership are not shareable.

Medical Condition(s)

In the past 36 months (9 months for pregnancy) have you or any family member applying for membership;