Medi-Share Committment for 18 year old
Participant and Parent

The Medi-Share guidelines state, “A child and a Participant parent must certify to CCM within 60 days after the child reaches the age of 18 that the child understands and lives by the lifestyle requirements for participation in his or her parent(s) household to continue. (Section III. Qualifications for Membership, Section A)

Please read the following commitments. The 18 year old must certify by initialing below whether they still meet the criteria for participation in the Medi-Share program. In addition, the parent must also attest that to their knowledge, their child does meet the qualifications for participation.

1 – I understand that any false statements on or omissions from this form will be future cause for immediate termination from the Medi-Share program. I understand that there is limited sharing during the first month of participation, (see Guidelines VII D).

2 – I understand that Christian Care Ministry, Inc. (CCM) matches a Medi-Share participant’s medical bills with other Participants who have volunteered, in faith, to share in meeting needs through the biblical concept of Christian mutual sharing. I further understand that all money comes from the voluntary giving of Medi-Share participants, not from CCM, and that CCM does not pay nor is it liable for the payment of any medical bills.

3 – I agree that in cases where all administrative appeals have been exhausted and after an appeal process, any and all remaining disputes will be settled solely as follows: by biblically-based mediation, not in a secular court, with each party to bear their own costs and attorney’s fees, and with the mediation fee itself to be borne by CCM. If resolution of the dispute and reconciliation do not result from mediation, the matter shall then be submitted to an independent and objective arbitrator for binding arbitration. The parties agree that the arbitration process will also be conducted in accordance with the Rules of Procedure for Christian Conciliation, with each party to bear their own costs and attorney’s fees, and with the arbitration fee itself to be borne by CCM. I agree that suing fellow Christians, including Christian ministries, is contrary to scripture; therefore, I will bring no suit, legal claim or demand of any sort against CCM in the civil court system, with the sole exception of enforcing any favorable arbitration award or mediated agreement.

4 – I understand that I will be responsible each month to access the website, which identifies a fellow Christian who will be receiving my gift toward their medical bills. I will endeavor to pray for this person and to give him or her encouragement by mail. I understand that the deposit of my monthly share by the first of each month enables timely sharing.

5 – I have carefully read and agree to abide by all provisions stated in the Medi-Share Guidelines. I hold to the conviction that the Bible teaches that we are to strive for healthy bodies, that we are our brother’s keeper, and that I have an obligation to share in my brother’s needs (Acts 2:42-47; Gal. 6:2; I John 3:16-17). All persons listed on this form believe that the body is the temple of the Holy Spirit, to be kept pure. We do not engage in sex outside of traditional Christian marriage. None of the persons listed on this form have used tobacco in any form or illegal drugs for the last 12 months; we commit to continue to abstain as Medi-Share participants. We agree not to abuse legal drugs, including alcohol. I understand that when a family member chooses not to live by these principles, I have a responsibility to notify CCM. I also realize the family member may be disqualified from Medi-Share and his or her bills will not be eligible for sharing.

6 – I understand that in order to determine the eligibility of the medical bills for sharing when an illness or injury occurs, medical records may be required from providers who have diagnosed or treated the participant. I understand and agree that no medical bill will be shared if authorization for obtaining such medical records is withheld.

Authorization for Release of Protected Health Information

1 – I authorize the disclosure of protected health information, including but not limited to, medical records, reports, pharmaceutical records, diagnostic test results, and lab test results.

2 – I understand that the following parties will receive this information about one or more of the applicants on this form in regard to enrollment in the proposed sharing program: Christian Care Ministry, Inc. (“CCM”), its employees, and authorized agents.

3 – Those parties that receive protected health information may disclose it for purposes of treatment, payment, or operations of Medi-Share®. They may otherwise disclose information only as allowed or authorized by law. These parties include insurers to which Proposed Participant has applied or may apply; pharmacy benefit managers, physicians, hospitals, clinics or other medical related facilities, health care clearing houses, or persons who perform tasks for them.

4 – I understand that this protected health information is needed for assistance in determining eligibility for enrollment in Medi-Share and to verify eligibility of the bills of those on this application that are submitted in the future.

5 – Unless revoked earlier, this authorization will be valid as long as the participants listed on this application are enrolled in Medi-Share plus 18 months from the date that their participation ends.

6 – I understand that I may revoke this authorization at any time by notifying CCM in writing at the address shown below, but if I do, it won’t have any effect on any actions taken prior to receiving the revocation.

7 – I understand that this authorization is voluntary; I understand that I may get a copy of this form after signing it.

8 – I understand that if an organization I authorize to receive the protected health information is not a health plan or healthcare provider, federal or state law may no longer protect the released information and it will no longer be private.

*Reminder: The Medi-Share Guidelines provide that failure to follow the Christian lifestyle attested to in the Commitments listed on the front page of this document may result in needs not being shared and termination.

VIII. Needs Not Shared By Members
C. Lifestyle Changes
Failure to follow the Christian lifestyle attested to during the application process can result in medical bills not being shared and, for Participants age 18 or older, termination of participation. Examples of behavior that can lead to non-sharing include, but are not limited to, the use of tobacco in any form, the abuse of drugs including legal drugs, such as, alcohol, and participation in activities with willful disregard for personal safety.

Type your initials to authorize the disclosure of protected health information as outlined in the above 8 statements.

Type your initials in agreement to the above six commitments as related to your status as the adult child or Parent of the Adult Child.