B Monroe Salon of Employee Enrollment Form True

B. Monroe Salon

Personalized Healthcare by MightyWELL
Primary Applicant Name*

First NameMiddle NameLast NameSuffix
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number*
Date of Birth *

MonthDayYear
Date
Gender *
Tobacco User?*

YesNo

Company Information
Company Name -please enter Macon or Warner Robins :

Click on next, if no spouse
Spouse's Name

First NameMiddle NameLast NameSuffix
Gender
Date of Birth

MonthDayYear
Date
Social Security Number

Click next, if no child(ren)

Click to open first child's application
First Child's Name

First NameMiddle NameLast NameSuffix
Gender
Date of Birth

MonthDayYear
Date
Social Security Number
Relationship to Primary Insured

Click to open second child's application
Second Child's Name

First NameMiddle NameLast NameSuffix
Gender
Date of Birth

MonthDayYear
Date
Social Security Number
Relationship to Primary Insured

Click to open third child's application
Third Child's Name

First NameMiddle NameLast NameSuffix
Gender
Date of Birth

MonthDayYear
Date
Social Security Number
Relationship to Primary Insured

ACKNOWLEDGEMENTS FOR THOSE ENROLLING IN ZION HEALTHSHARE

Please Read & initial
Providing us with authorization to email and text you will allow Zion HealthShare to exchange information with you more

efficiently and will benefit you as a member. At the same time, we recognize that email and text messaging are not a

You are not required to authorize the use of email and text messages and a decision to not authorize electronic communication will not affect your health care in any way.

We have taken considerable effort to protect the personal health information of our members, and recommend that all members provide us with this authorization so that we can more efficiently communicate with them.
I agree*

YesNo
Pre-Membership Medical Conditions Limitations
Any illness or accident for which a person has been diagnosed, received medical treatment, been examined, taken medication, or had symptoms for 24 months prior to the Effective Date. Needs that result from a pre-membership medical condition that existed pror to a Member's Effective Date (known or producing observable sysmptons) are only shareble if the condition appears to be fully cured and 24 months have passed weithout any symptoms (either bening or deleterious). treatment, or medication, even if the cause of the symptons is unknown or misdiagnosed.
I Agree*

YesNo
Waiting Period
In the first year of Membership, pre-existing conditions have a waiting period and are not sharable with the Zion Healthshare community yet. After the first year of continuous Membership, uo to $25,000 can be shared with thecommunity. After the second year of continuous Membership, up to $50,000 can be shared with the community. After the third year of continuous Membership and going forward, up to $125,000 can be shared with the community.
I Agree*

YesNo
MEMBERSHIP START DATE*

MonthDayYear
Date

MightyWELL Representative
Representative Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com

Signature
Signature*

Clear
DATE*

MonthDayYear
Date
Should be Empty:

B. Monroe Salon

Click on next, if no spouse

Click next, if no child(ren)

ENROLLMENT SELECTION

ACKNOWLEDGEMENTS FOR THOSE ENROLLING IN ZION HEALTHSHARE

Pre-Membership Medical Conditions Limitations

Waiting Period

MightyWELL Representative

Signature