AHCC Enrollment Forms

Apollo HealthCare Cooperative ENROLLMENT FORM   –   PLEASE PRINT, SIGN AND BRING TO OFFICE

1269-C 16th Street NE Hickory, NC 28601 Ph. 828-256-1471 www.apollohealthcarecoop.org

ENROLLMENT FEE: $30 – One Time per family
PLAN TYPE: PREMIUM CARE – $45 per month— CHILD (under 18) – $30 per month

PLAN TYPE:    Premium Care Adult  _____    Premium Care Child  _____

Please Print All Information. A separate enrollment form must be completed for each person enrolling. If enrolling a child also please fill out the parent information. All members enrolling will be required to prepay the first 3 months of membership. You will be able to choose your healthcare provider from our list of providers under this co-op plan. Co-op members are responsible for all charges incurred for any services rendered outside of your providers office.

NAME (First) ____________________ MI___ (Last) _____________________SEX (M/F) ___ DATE OF BIRTH: _____________
MAILING ADDRESS______________________________________ CITY_____________________ STATE____ZIP___________
PHONE (H) ___________________ (Cell) ___________________ (W) ___________________ EMAIL_______________________
EMERGENCY CONTACT__________________________________________________ PHONE ___________________________
PARENT NAME (if enrolling child) ________________________ADDRESS (if different than child) ________________________

DO YOU CURRENTLY HAVE HEALTH INSURANCE? _____

Name of Ins. Co. ________________Deductible Amount____________

ARE YOU INTERESTED IN TALKING WITH SOMEONE ABOUT A HOSPITALIZATION INSURANCE PLAN? (Yes/No)____ Providers cannot bill any insurance companies or Medicare/Medicaid for any medical fees while you are a Co-op Member. The co-op can provide a statement of co-op fees paid to assist you in making any HSA claims. Questions concerning the co-op fees and your high-deductible insurance plan are between the Member and their Insurance Company.

DECLARATIONS AND SIGNATURES RELATED TO MEMBERSHIP AGREEMENTS
I agree to be a member of the Apollo Health Care Cooperative Association (AHCC) in order to have access to the benefits and privileges of the Association and its Co-op Medical clinic programs and group health insurance plans. I, therefore, acknowledge that I have read and agree to the Enrollment Terms and Conditions of AHCC and to the Agreement for Apollo Healthcare Cooperative Assoicates. ALL MEMBERS MUST SIGN BELOW.

Signature _____________________________________ Date ___________

Membership Start Date ______________

All completed enrollments and payments received in the co-op office by the 20th of the
month will have a membership start date on the 1st of the next month. (Refer to the
AHCC Enrollment Terms and Conditions regarding effective membership start dates.)

(Office use only)
Date _______________
Amount ____________
Pmt Type __________
Months_____________
By _________________
Agent______________
Referral/Partial/Full                                                 Revision 12/18/2012                                     Enrollment Counselor  _____________________

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