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)
Pmt Type __________
Referral/Partial/Full Revision 12/18/2012 Enrollment Counselor _____________________