Big Stuff Health Share Enrollment Form

1
Name* This field is required.
First Name
Last Name
2
Preferred name or nickname (if any):
3
How did you hear about Big Stuff Health Share?* This field is required.Please mark all that apply.
A friend or family member
My primary care doctor
An Alive & Well representative
Online search
Social media
Advertisements
Other
4
Please let us know who referred you:
5
Gender* This field is required.
Female
Male
6
Will you turn 60 or older this year?* This field is required.
YESNO
7
Date of Birth* This field is required.
Month
Day
Year
8
Please say cheese!Take a selfie so we can put a face to your name when we help you. Don't worry if the image looks stretched.
9
Relationship
Primary
Primary
10
Cell Phone Number* This field is required.Notice: We provide access to Alive & Well direct primary care providers via text message with for your convenience. Please note that messages sent via standard SMS and iMessage are not encrypted or secured. By providing your cell phone number here, you accept these risks. (Please contact our team if you prefer to use our secure messaging system instead.)
Notice: We provide access to Alive & Well direct primary care providers via text message with for your convenience. Please be advised that messages sent via standard SMS and iMessage are not encrypted or secured. This means that a third party may be able to access personal health information. By providing your cell phone number here, you state that you accept these risks. (If you prefer a secure messaging system, please contact our team.)
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Email* This field is required. Notice: We allow members to email about medical services and billing for your convenience. Please be advised that messages sent via email are not encrypted or secured. By providing your email address here, accept these risks if you choose to email about your healthcare needs or history. (You may also use a secure form to submit health-related information linked at bigstuffhealthshare.com.)
12
Home Address* This field is required.
Street Address
Street Address 2
City
State
ZIP Code
United States
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
13
Is your home address the same as your mailing address?* This field is required.
YESNO
14
Mailing Address* This field is required.If different from your home address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
15
How many family members are you including in your membership?* This field is required.Family members may include a spouse and /or children who live in the same household. Must be a state recognized, legal marriage or guardianship. Dependent children must be age 25 or younger. Increased contributions apply for 9 or more family members. See pricing at https://www.bigstuffhealthshare.com/.
Just me
Me + 1 family member
Me + 2 or more family members
16
Which family members are you including in your membership?* This field is required.May include a spouse and children who live in the same household. Must be a state recognized, legal marriage or guardianship. Dependent children must be age 25 or younger. An increased contribution applies for 9 or more family members.
Just me
Me + Spouse
Me + Spouse + Child(ren)
Me + Child(ren)
17
Are you and your spouse legally married under applicable state law?* This field is required.Only legally married spouses can be included on the same health share membership.
Yes
No
18
Spouse's Full Name* This field is required.
First Name
Last Name
19
Spouse's Gender* This field is required.
Male
Female
20
Will your spouse turn 60 or older this year?
YESNO
21
Spouse's Date of Birth
Month
Day
Year
22
Spouse's Phone Number* This field is required.
Area Code
Phone Number
23
Spouse's Email* This field is required.
example@example.com
24
Are you a legal guardian of all the children you will be listing?* This field is required.Only children of whom you are a legal guardian may be included on the same membership. If you have questions about this policy, please feel free to reach out to info@myaliveandwell.com.
Yes
No
25
Children's Information* This field is required.You may include dependent children who are age 25 or younger and not married. An increased contribution applies for 9 or more family members.
Gender
Date of Birth (mm/dd/yyy)
Phone Number (if over age 21)
Child's Name
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Child's Name
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Child's Name
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Child's Name
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Child's Name
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Child's Name
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Child's Name
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Child's Name
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Child's Name
Child's Name
Child's Name
Child's Name
Child's Name
Child's Name
Child's Name
Child's Name
Gender
Row 0, Column 0
Date of Birth (mm/dd/yyy)
Row 0, Column 1
Phone Number (if over age 21)
Row 0, Column 2
Gender
Row 1, Column 0
Date of Birth (mm/dd/yyy)
Row 1, Column 1
Phone Number (if over age 21)
Row 1, Column 2
Gender
Row 2, Column 0
Date of Birth (mm/dd/yyy)
Row 2, Column 1
Phone Number (if over age 21)
Row 2, Column 2
Gender
Row 3, Column 0
Date of Birth (mm/dd/yyy)
Row 3, Column 1
Phone Number (if over age 21)
Row 3, Column 2
Gender
Row 4, Column 0
Date of Birth (mm/dd/yyy)
Row 4, Column 1
Phone Number (if over age 21)
Row 4, Column 2
Gender
Row 5, Column 0
Date of Birth (mm/dd/yyy)
Row 5, Column 1
Phone Number (if over age 21)
Row 5, Column 2
Gender
Row 6, Column 0
Date of Birth (mm/dd/yyy)
Row 6, Column 1
Phone Number (if over age 21)
Row 6, Column 2
Gender
Row 7, Column 0
Date of Birth (mm/dd/yyy)
Row 7, Column 1
Phone Number (if over age 21)
Row 7, Column 2
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Do you have signs, symptoms, or a diagnosis of:* This field is required.Select all that apply. If you choose "Other," please type your condition within the "Other" box.
Cancer
Heart Condition
Diabetes
Asthma
Previous Surgery
Drug Allergies
Currently pregnant
I have no history of these or any other major medical issues or concerns.
Other
27
If you've had any surgeries or medical procedures done, please list the type and date below.
Huge
Large
Normal
Small
Ok
Ok
28
Please list any allergies below.
Huge
Large
Normal
Small
Ok
Ok
29
Spouse and children medical history. * This field is required.Click the "+" symbol to add an individual or condition.
30
Pre-Existing Conditions* This field is required.A pre-existing condition is any illness or injury existing or occurring within 24 months before the effective date for which a member: ● Had symptoms; ● Has been diagnosed; ● Received medical treatment; ● Has been examined; or ● Has taken medication An otherwise Eligible Medical Need resulting from a pre-existing condition will only be Shareable during the first 12 months after the Effective Date if the condition is: 1. Fully cured and 2. Symptom- and treatment-free for 24 months before the Effective Date Pre-Existing Condition Waiting Period Pre-Existing Conditions have a waiting or phase-in period based on years of continued Membership: 1st Year – Waiting Period for all Pre-Existing Conditions. No otherwise Eligible Medical Needs considered Pre-Existing Conditions will be shared or paid during the first 12 months after the Effective Date 2nd Year – Up to $25,000 of Eligible Medical Needs considered Pre-Existing Conditions may be Shareable 3rd year – Up to $50,000 of Eligible Medical Needs considered Pre-Existing Conditions may be Shareable 4th year and beyond – Up to $100,000 per year of Eligible Medical Needs considered Pre-Existing Conditions may be Shareable. Maternity Needs may only be Shareable if conception occurs 90 days or longer after the applicable Member’s Effective Date. This program exists to help protect existing Members’ contributions from immediate, extensive medical out-payments for conditions existing before the membership for newly added Members. * *Please speak with a Big Stuff representative if you have concerns about pre-existing conditions. We want to make sure you have a plan that meets your needs.
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What "big stuff" runs in your family? Think about your parents and grandparents on both sides. This may help us guide you to preventive care. :)* This field is required.Select all that apply. If you choose "Other," please type your condition within the "Other" box.
Skin cancer
Colon cancer
Breast cancer
Stroke
Heart Attack
Other cancer
Other Heart Conditions
Diabetes
Asthma
None
Other
32
Do you or any family members enrolling with you take medications for chronic medical conditions (such as insulin or blood thinners)?* This field is required.
YESNO
33
If you or a family member takes any medications, please list the name, dosage, and purpose of the medication below.* This field is required.If nothing, please write "N/A."
Huge
Large
Normal
Small
Ok
Ok
34
Guideline on Prescription Medications* This field is required.The Big Stuff Health Share community does not share costs of prescriptions for ongoing needs such as diabetes or heart conditions. We may, however, share the costs of medications related to incidents such as a hospitalizations or surgeries. We are happy to point members to outside resources to obtain medications for chronic conditions at discounted rates.
35
What "big stuff" runs in your spouse's family? Think about his/her parents and grandparents on both sides. This may help us guide them to preventive care.* This field is required.Select all that apply. If you choose "Other," please type your condition within the "Other" box.
Skin cancer
Colon cancer
Breast cancer
Stroke
Heart Attack
Other cancer
Other Heart Conditions
Diabetes
Asthma
None
Other
36
Are there any members in your household that use tobacco and/or vape products?* This field is required.(This includes smokeless tobacco and non-nicotine vape products. Households that use tobacco are charged an additional fee due to related health risks.)
YESNO
37
Notice of Complete Information* This field is required.
38
Notice of Privacy Practices* This field is required.
39
Who can we share your medical information with if needed?HIPAA RELEASE OF INFORMATION - By entering the full names of individuals in the following blanks, I am authorizing the release of my medical information (including the diagnosis, records, and examination rendered to me as well as claims information) to those listed below. I also understand this does not take effect unless the full names of individuals are entered.
Person 1
Person 2
40
Health Share Foundations for Membership* This field is required.Each Member must comply with the following requirements in order to preserve its membership and be eligible to participate in the sharing program. The requirements below benefit all Members by assuring honor and integrity on the part of Members and by minimizing medical risks and ensuring proper accountability while encouraging good health practices. All Members must agree with and attest to the following statements: 1. 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. 2. I understand that Big Stuff Health Share is a Benevolence Organization, not an insurance entity and that while Big Stuff Health Share assures that every effort will be made to have Members fulfill their monthly sharing commitment, Big Stuff Health Share, in and of itself, cannot guarantee payment of any medical expenses. 3. I agree to practice good health measures and strive for a balanced lifestyle. 4. 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. 5. 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. 6. I agree to submit to mediation followed by subsequent binding arbitration, if needed, for any instance of a dispute with Big Stuff Health Share or its affiliates. 7. I agree to sign and submit a membership continuation agreement each renewal year confirming my commitment to adhere to these principles.
41
Member Guidelines* This field is required.
42
Initial Unshared Amount (IUA), aka "Whatcha Gotta Pay First"* This field is required.This is the amount you'll pay out of pocket to your medical provider for each Medical Need before the rest can be shared by the community. These rates are: $2,000 for members ages 0-39 $3,500 for members ages 40+. (For maternity needs, the member will be responsible for two IUA’s: one IUA for mom, and a 50% IUA for the baby.)
43
Commitment of Intent* This field is required.Thank you for becoming a part of Big Stuff Health Share (BSH). It is important that you fully understand that Big Stuff Health Share is a group of individuals who voluntarily assist each other with certain medical costs and has no relationship with insurance. If you have any questions, please email the office at help@bigstuffhealthshare.com. Please read each of the following: I understand that my monthly contribution to Big Stuff Health Share enables BSH to help me in the following ways: 1. To use the 24/7 Medical HelpLine to speak with medical professionals about my medical needs and create a treatment plan with a Big Stuff Health Share / Alive & Well medical provider. 2. To keep on file information concerning my membership or my family’s membership 3. To help me complete shared need requests and share medical needs as appropriate under BSH guidelines. I understand that Big Stuff Health Share is not insurance or endorsed by the Department of Insurance in my state and that claims or losses are not protected by the state guaranty fund. I understand that BSH is under no legal obligation to disburse funds to me or other participants and that my needs may be accepted or rejected according to the member guidelines. Likewise, the responsibility of payment of any medical bills or needs remains with me. I understand that part of my monthly financial contribution goes toward a minimal administrative expense to operate the Big Stuff Health Share office. I understand that participants send money to help one another out of a desire to offer a more affordable solution for healthcare expenses. It would be an abuse of their trust and will render me ineligible for membership in Big Stuff Health Share if I use money I receive for a shared need for any purpose other than payment of that need. I attest that the information I have provided about myself and my family is true and complete, and that I have read and understand the above statements. I understand that Big Stuff Health Share is NOT insurance and I should present myself as a “cash pay” patient and request “cash pay pricing” for medical treatment. I am willing to contact the 24/7 Medical HelpLine to obtain provider instructions before seeking medical treatment for non-emergent care.
44
Consent* This field is required.By signing below, I acknowledge that I seek and consent to Alive & Well medical and wellness services via Big Stuff Health Share. I agree to comply with all of the policies and procedures of the Big Stuff Health Share program, including those outlined in this enrollment form. I also agree to receive text and email communications from Big Stuff Health Share (including communications via the Alive & Well telemedicine provider). I'm aware this consent does not cover treatment by providers or affiliates outside of the Alive & Well provider team. I certify that all information provided as part of this agreement is true and correct to the best of my knowledge. Finally, by signing, I'm aware that I, the enrollee, am stating that I was present for the filling out of this form.
45
Bank Name* This field is required.Ex: Wells Fargo
46
Bank location city and state* This field is required.Ex: Salt Lake City, Utah
47
Is this a checking or savings account?* This field is required.
Checking
Savings
48
Full name of the person listed on the account* This field is required.
49
Full account number* This field is required.
50
Bank routing number* This field is required.
51
Authorization to withdraw. Please review and sign:I authorize Alive & Well™, in conjunction with Big Stuff Health Share, to debit my bank account on the first of each month for payment of HealthCARE membership fees. I understand and agree that any and all requests for changes in my account information, including requests to terminate this agreement, must be received by Big Stuff Health Share / Alive & Well™ by the 25th of the month prior to the next due date. If the payment due date falls on a weekend or holiday, the payment may be executed on the next business day. I understand and agree that as this is an electronic transaction, adequate funds must be available for withdrawal from my account by the payment due date. In the case of an ACH transaction being rejected for Non-Sufficient Funds, or any other purchaser error, Big Stuff Health Share / Alive & Well™ may at its discretion resubmit the ACH debit transaction, including a 3.5% late charge. I acknowledge that the origination of ACH transactions to my account must comply with provisions of U.S. law and agree not to dispute this recurring billing so long as the transactions correspond to the terms indicated in this authorization form.
52
Notice of Membership Start Date Policy* This field is required.
Should be Empty: