Add a Member: Medical History Questionnaire

  • Add a Member: Medical History Questionnaire

    Please provide detailed medical information for each Applicant / Dependent you would like added to your Solidarity HealthShare membership.

  • Note: Your privacy is very important to us. To better serve you, the form information you enter is recorded in real time.

    Thank you for helping the Solidarity HealthShare community to grow!

    A few quick notes before you get started:

    • This form is for an individual applicant.
      • Please fill out this form for each Member you would like to add to your Membership.
    • Please note that the medical history questionnaire asks detailed questions. If you need additional time to gather the necessary details, you are able to save your application and return at a later time. At the bottom of each page of the application, there is a button to "Save and Resume Later." If you decide to use this feature, you have 30 days to return to complete your form and must use the link provided to retrieve your progress.
    • At the very end of the form, you will be required to electronically sign your questionnaire.
    • Solidarity HealthShare is committed to the confidentiality of information submitted in this application form. For more details, please review our Privacy Policy.

  • Add a Member Selection

    Please choose which version of the Add a Member Medical History Questionnaire form you need to fill out.

  • Existing Membership: Primary Member Info

    Help us find the right existing membership to add this new Member. Please provide information about the Primary Member on your existing Solidarity HealthShare Membership.
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  • If you have questions about this Add a Member form, please reach out to our team on the ShareStream in the Member Care Portal or by email at: support@solidarityhealthshare.org. We are happy to assist you.

  • Adding a Dependent: Primary Applicant Info

    Help us find the right application to add this Dependent. Please provide information about the Primary Applicant from your application to join Solidarity HealthShare.
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  • If you have questions about this Add a Dependent form, please call the Onboarding team at (844) 313-4999 + select Option 4. Or reach the team via emailt at: memberdevelopment@solidarityhealthshare.org. We are happy to answer any questions you may have.

  • Applicant Information

    Please provide the following information for the new Applicant you wish to add to your Membership.
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  • Adult Dependents

    Solidarity HealthShare does allow for Adult Dependents to join their parents or guardians on a Membership or as part of a Sponsored Membership under certain requirements.

  • Adult Dependent Eligibility

    We show that your answers and selections result in the Dependent Applicant being at least twenty years old.

    Based on the above, we have determined your Dependent may require additional Medical Review to determine their eligibility on your Solidarity membership.

  • Learn More about Dependents

    To learn more about the types of Dependents allowed on your membership and what you can expect when discussing with our Onboarding and Enrollments team: Learn More

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  • Applicant: General Medical

    Please answer the following general health questions for the Applicant.
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  • Solidarity Well

    Solidarity Well was created so that members of Solidarity HealthShare could share the needs of chronic conditions that are particularly responsive to lifestyle changes. It is based upon our shared belief that we are all creatures of God and have a moral and spiritual obligation to care for our bodies. Solidarity Well provides scientifically proven resources and coaching to support Solidarity Well members' health and provide effective stewardship of the resources as a community. A member can graduate from Solidarity Well once the condition's health metrics are reached.

  • Possible Conditions for Enrollment

    We show that you answered 'Yes' to at least one of the following conditions:

    • Diabetes
    • High Blood Pressure
    • High Cholestorol
    • Osteoperosis
    • Nicotine/Tobacco Use
    • Possible Obesity (height and weight calculation of a BMI result outside the recommended guidelines)

    Based on some of your answers above, we have determined you may require additional Medical Review to determine your eligibility for the Solidarity Well program.

  • Learn More about Solidarity Well

    To learn more about the Solidarity Well program and what you can expect when discussing with our Onboarding and Enrollments team: Learn More

  • Applicant: Medical History

    Please answer the following health questions for the Applicant.

  • For this next section, please indicate if the Applicant has ever been diagnosed and/or treated for any of the following diseases or conditions. For your convenience, you only need to update the fields that apply to the Applicant.

    Note: Please be careful to read through each item as any prior medical condition not included in this application that is discovered later will be retroactively considered a pre-existing condition. 

  • Please select any of the following the Applicant has been diagnosed and/or treated for in the last 24 months.

  • Chronic Infectious Diseases Details

  • For each box you checked above, please list the following:

    • Date of onset/diagnosis
    • Date of the last visit for the condition, and
    • Any previous or ongoing treatment

    Note: Use a new line for each separate condition you have selected.

  • Musculoskeletal System Details

  • For each box you checked above, please list the following:

    • Date of onset/diagnosis
    • Date of the last visit for the condition, and
    • Any previous or ongoing treatment

    Note: Use a new line for each separate condition you have selected.

  • Autoimmunity Details

  • For each box you checked above, please list the following:

    • Date of onset/diagnosis
    • Date of the last visit for the condition, and
    • Any previous or ongoing treatment

    Note: Use a new line for each separate condition you have selected.

  • Neurological Disease Details

  • For each box you checked above, please list the following:

    • Date of onset/diagnosis
    • Date of the last visit for the condition, and
    • Any previous or ongoing treatment

    Note: Use a new line for each separate condition you have selected.

  • Pulmonary Disease Details

  • For each box you checked above, please list the following:

    • Date of onset/diagnosis
    • Date of the last visit for the condition, and
    • Any previous or ongoing treatment

    Note: Use a new line for each separate condition you have selected.

  • Gastrointestinal Disorders Details

  • For each box you checked above, please list the following:

    • Date of onset/diagnosis
    • Date of the last visit for the condition, and
    • Any previous or ongoing treatment

    Note: Use a new line for each separate condition you have selected. If you answered 'Yes' to the colonoscopy question, please provide information about the results.

  • Genetic or Congenital Disorders Details

  • For each box you checked above, please list the following:

    • Date of onset/diagnosis
    • Date of the last visit for the condition, and
    • Any previous or ongoing treatment

    Note: Use a new line for each separate condition you have selected.

  • Mental/Emotional Health Details

  • For each box you checked above, please list the following:

    • Date of onset/diagnosis
    • Date of the last visit for the condition, and
    • Any previous or ongoing treatment

    Note: Use a new line for each separate condition you have selected.

  • Cardiovascular Disease Details

  • For each box you checked above, please list the following:

    • Date of onset/diagnosis
    • Date of the last visit for the condition, and
    • Any previous or ongoing treatment

    Note: Use a new line for each separate condition you have selected.

  • Endocrine / Metabolic Disease Details

  • For each box you checked above, please list the following:

    • Date of onset/diagnosis
    • Date of the last visit for the condition, and
    • Any previous or ongoing treatment

    Note: Use a new line for each separate condition you have selected.

  • Urinary System Details

  • For each box you checked above, please list the following:

    • Date of onset/diagnosis
    • Date of the last visit for the condition, and
    • Any previous or ongoing treatment

    Note: Use a new line for each separate condition you have selected.

  • Blood Disorders Details

  • For each box you checked above, please list the following:

    • Date of onset/diagnosis
    • Date of the last visit for the condition, and
    • Any previous or ongoing treatment

    Note: Use a new line for each separate condition you have selected.

  • Cancer / Benign Tumors Details

  • For each box you checked above, please list the following:

    • Date of onset/diagnosis
    • Date of the last visit for the condition, and
    • Any previous or ongoing treatment

    Note: Use a new line for each separate condition you have selected.

  • Skin Conditions Details

  • For each box you checked above, please list the following:

    • Date of onset/diagnosis
    • Date of the last visit for the condition, and
    • Any previous or ongoing treatment

    Note: Use a new line for each separate condition you have selected.

  • Female Reproductive System Details

  • For each box you checked above, please list the following:

    • Date of onset/diagnosis
    • Date of the last visit for the condition, and
    • Any previous or ongoing treatment

    Note: Use a new line for each separate condition you have selected.

  • Male Reproductive System Details

  • For each box you checked above, please list the following:

    • Date of onset/diagnosis
    • Date of the last visit for the condition, and
    • Any previous or ongoing treatment

    Note: Use a new line for each separate condition you have selected.

  • Anything Else?

  • For each box you checked above, please list the following:

    • Date of onset/diagnosis
    • Date of the last visit for the condition, and
    • Any previous or ongoing treatment

    Note: Use a new line for each separate condition you have selected.

  • Acknowledgments

    You will be required to electronically sign this application prior to submission. Please read the following statements carefully.

  • PROGRAM, NOT INSURANCE. I acknowledge that I am enrolling in Solidarity HealthShare, a healthcare sharing ministry of Melita Christian Fellowship Hospital Aid Plan, that is voluntary and cooperative and not insurance. I have read and understand any disclaimer to this effect and understand that there are no representations, promises or guarantees that my medical expenses will be paid. I also understand that any funds that I may receive for medical expenses do not come from an insurance plan but are voluntary donations by the members.

    SIXTY-DAY WAIT. I acknowledge that for sixty (60) days after enrollment and acceptance as a Sharing Member, medical expenses for any reason, other than accident, emergencies, and acute illness, are not eligible for sharing among members.

    CHANGES TO SHARING GUIDELINES. I acknowledge that amendments to the Guidelines will take effect as soon as is administratively practical or as designated by the Board of Directors. Dates of Service of medical expenses submitted for sharing will be subject to the edition of the Guidelines in effect when recorded as received by Solidarity HealthShare and supersedes all other editions of the Guidelines and any other communications, written or verbal.

    APPLICATION FEE REFUND. I acknowledge that the $135 application fee will be refunded if all individuals on my application are declined for membership, or if I withdraw my application prior to my membership effective date. I also understand that the annual membership dues will not be refunded if, in the course of applying for membership, I fail to respond to written or verbal inquiries from Solidarity HealthShare for more than sixty (60) days.

    CALCULATIONS OF SUGGESTED MONTHLY CONTRIBUTION. I acknowledge that the suggested Monthly Contribution is calculated on the total number of healthcare sharing ministry members, the amount of medical expenses submitted for sharing, and the administrative cost of operating the healthcare sharing ministry program. I further acknowledge that the suggested Monthly Contributioni is calculated on a periodic basis as needed and is subject to change. I understand that the donation of the Suggested Monthly Share Amount is voluntary and that I am not obligated to send any money.

    ACCOUNT FEE. I acknowledge that if I make my Monthly Contribution by credit card or check payment method I will see a $10 Account Fee added to my Share Notice each month. I also understand Members can receive a $10 discount by using ACH as their method of payment to make their Monthly Contribution.

    OPTIONAL COMMUNICATION BETWEEN MEMBERS. I acknowledge that Solidarity HealthShare’s cost sharing technology also enables members to send one another notes of encouragement or prayer and, upon activation, that each member can choose how to be identified in this system or to remain anonymous.

    APPLICATION ACCEPTANCE. I acknowledge that Solidarity HealthShare, pursuant to the Sharing Guidelines, has the discretion to accept, reject, or modify my membership. I will not assume that my application has been accepted until I have received a written confirmation from Solidarity HealthShare.

    MEDICAL HISTORY QUESTIONNAIRE. I acknowledge that I submitted a full and complete medical history for all individuals on this application at the time the application was submitted. I understand that the Solidarity HealthShare team will review the medical history for each individual and will contact me with any questions prior to my membership being accepted. If there are any changes to the medical history for any individual on this application prior to this membership being accepted or membership effective date, I will inform the Solidarity HealthShare team. I understand that the effective date selected and the sharing of any conditions listed on the Medical History Questionnaire are dependent on the medical review and enrollment process consistent with the guidelines of Solidarity HealthShare.

    ACCEPTANCE OF GUIDELINES. I have read and understand the Sharing Guidelines and accept them as the guiding document for all interactions among members and for determining the eligibility of medical expenses that I may submit for sharing. If a difference of opinion should arise as to the use, application or interpretation of those Sharing Guidelines, I will follow the appeal process outlined in the Sharing Guidelines for the resolution of any or all disputes. I acknowledge that I will treat all Solidarity HealthShare employees and representatives with mutual kindness and respect as taught by the Gospel of John 13:34 “I give you a new commandment: love one another. As I have loved you, so you also should love one another.”

    PAYMENT OF MEDICAL NEEDS. I acknowledge that any medical need shared will be used for the sole purpose for which it was shared.

    STATEMENT OF BELIEFS. Solidarity HealthShare is made up of like-minded individuals who voluntarily share one another’s medical expenses. Our core ethical beliefs mobilize our actions, and we related to one another in community because of them. We ask that each member subscribe to the following Shared Beliefs:

    1. We believe that our personal rights and liberties originate from and are bestowed on me by God and are not concession granted to us by governments or men.
    2. We believe every person has a right to exercise his or her religion without interference or coercion. While we do not hold that every claim made in the name of religion has equal merit or equal basis in truth, we do respect each person’s freedom of both religious worship and practice.
    3. We believe it is our moral and ethical obligation to be our brother’s or sister’s keeper, in recognition of the principle of solidarity, according to our God-given resources and opportunity.
    4. We believe in the virtue of temperance, which enables us to maintain a healthy lifestyle and avoid foods, behaviors, or habits that could produce sickness or disease.
    5. We believe it is our fundamental right of conscience to direct our own healthcare, in consultation with physicians, family or other valued advisors, free from government dictates, restraints and oversight, including federal or state contraception and abortion mandates and all unethical practices or mandates.
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  • Protected Health Information

    You will be required to electronically sign this application prior to submission. Please read the following statement carefully.

  • Solidarity HealthShare has requested and will receive from me and my healthcare providers health information prior to my enrollment in Solidarity HealthShare. Solidarity HealthShare will use this information to determine whether I am eligible to enroll. Solidarity HealthShare will protect the confidentiality of that information in the same manner as all other health information Solidarity HealthShare maintains and, if I do not enroll, Solidarity HealthShare will not use or disclose the information Solidarity HealthShare obtained for any other purpose.

    Solidarity HealthShare will make disclosures of my health information as necessary for my treatment. A doctor or health facility involved in my care may request some of my health information that Solidarity HealthShare holds in order to make decisions about my care. Solidarity HealthShare will use and disclose my health information as necessary for payment purposes. For instance, Solidarity HealthShare may use information regarding my medical procedures and treatment to process and arrange for the payment of medical bills, to determine whether services are medically appropriate or to otherwise pre-authorize or certify services as eligible to be shared under the Guidelines. Solidarity HealthShare may also forward such information to another health plan that may also have an obligation to process and pay expenses on my behalf.

    Solidarity HealthShare will use and disclose my health information as necessary for healthcare operations which include peer review, business management, accreditation and licensing, utilization review and management, quality improvement and assurance, enrollment, voluntary disclosure of health conditions, compliance, auditing, and other functions related to my healthcare management. Solidarity HealthShare may also disclosure my health information to another healthcare facility, healthcare professional, or health plan for such things as quality assurance and case management, but only if that facility, professional, or plan also has or had a patient relationship with me.

    Solidarity HealthShare may from time to time disclose my health information to family, friends, and others who are involved in my care or in payment for my care in order to facilitate that person's involvement in caring for me or paying for my care. If I am unavailable, incapacitated, or facing an emergency medical situation and Solidarity HealthShare determines that a limited disclosure may be in my best interest, Solidarity HealthShare may share limited health information with such individuals without my approval. Solidarity HealthShare may also disclose health information to an entity that is authorized to assist in disaster relief efforts in order for that entity to locate a family member or other persons that may be involved in some aspect of caring for me.

    Certain aspects and components of Solidarity HealthShare services are performed through contracts with outside persons or organizations such as legal services, Utilization Management Services, Preferred Provider Organizations, Pharmacy Benefit Managers, etc. At times it may be necessary for Solidarity HealthShare to provide some of my health information to one or more of these outside persons or organizations who assist with healthcare operations.

    Solidarity HealthShare may communicate with me regarding my medical expenses, share amount, or other matters related to my health.

    Solidarity HealthShare may, from time to time, use my health information to determine whether I might be interested in or benefit from treatment alternatives or other health-related programs, products or services which may be available to me as a member. Solidarity HealthShare may use my health information to identify whether I have a particular illness, and contact me to advise me that, as a member, a disease management and/or wellness program may help me manage my illness or health condition.

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  • Review & Agreement

    Please review your following selections to confirm their accuracy. You will be required to agree to this Medical History's selections and information by electronically signing prior to submission.

  • Primary Member Information

  • Primary Applicant Information

  • Primary Name {applicantExistingPrimaryMembershipName}{dependentPrimaryApplicantName}
    Date of Birth: {applicantExistingPrimaryMembershipDOB}{dependentPrimaryApplicantDOB}
    Email on Record: {applicantExistingPrimaryMembershipEmail}{dependentPrimaryApplicantEmail}

  • Add a Member to Existing: Applicant Review

  • Applicant Name: {applicantName}
    Gender: {applicantGender}
    Age: {hiddenApplicantCurrentAge}
    Spouse or Dependent? {addedMemberSpouseOrDependent}
    Adult Dependent? {applicantAdultDependentAcknowledgment}{hiddenAdultDependentNoAnswerField}
       
    Additional Coverage? {applicantCOBSelection}
    Insurance Provider: {applicantCOBHealthInsurance} | {applicantCOBPolicyNumber} | {applicantCOBCoverageStartDate}
    Medicare: {applicantCOBMedicarePlanNumber} | {applicantCOBMedicareStartDate}

    Continuing Coverage?

    		 {applicantCOBPlanningToContinue}

  • Add a Dependent to Application: Applicant Review

  • Applicant Name: {applicantName}
    Gender: {applicantGender}
    Age: {hiddenApplicantCurrentAge}
    Adult Dependent? {applicantAdultDependentAcknowledgment}{hiddenAdultDependentNoAnswerField}

  • Final Agreement & Signature

  • By signing below, I acknowledge that I have read this entire agreement in full and agree to comply with the above polices and guidelines of Solidarity HealthShare and acknowledge that I understand all terms, language, and concepts herein.

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