Member Application Form

• I agree to comply with the Medical Aid & Alms Plan Complete Guidelines. I acknowledge that I have an adequate
understanding of the Plan and its limitations, and that my participation is strictly voluntary. I understand that the plan will be active on the effective date listed in my application confirmation letter.
• I certify that the information provided in this application is true, accurate, and complete to the best of my knowledge.
• I understand that Anabaptist Brotherhood Medical Aid & Alms Plan is not insurance and should never be construed as
a contract for health insurance. I hold ultimate responsibility and am legally liable for the payment of my own medical
bills. Brotherhood offers no legal guarantee and shall not be legally liable for the payment of my medical bills. Further, I understand that no Member shall be forced or compelled to make sharing contributions. Contributions from Members are voluntary gifts and are non-refundable. If sharing occurs, the shared medical expenses are paid solely from
voluntary contributions of Members. Brotherhood serves to facilitate this mutual sharing by managing the Members’
pooled funds for those who have eligible expenses.
• I authorize Anabaptist Brotherhood to use and disclose my medical information for purposes of cost sharing, case
management, and general organizational use. I grant permission to negotiate and pay bills on my behalf. I authorize
Brotherhood to discuss any medical bills with my church’s contact person. Any information shared will be limited
to what’s necessary to support the coordination of my medical care and the sharing of eligible expenses within the
ministry.