Enrollment Forms

ANSARI HEALTHSHARE ENROLLMENT CHECKLIST!

STEP 1- PAGE 1-NAMES, ADDRESSES AND DEPENDENTS INFORMATION

Make sure to List everyone that you are applying for on this form. Person(s) 26 yrs. of age or older will have to apply separately for themselves and not as a dependent. (see Guidelines) Return Completed Page 1 back to Ansari HS.

STEP 2- PAGE 2a and 2b-CONFIRMATION/ACKNOWLEDGEMENT FORM

Make certain to print and sign at the bottom of page 2b to all that applies to you and keep a copy for your records. **Return Completed Page 2b back to Ansari Healthshare.

STEP 3- PAGE 3a & 3b- MEDICAL HISTORY QUESTIONNAIRE FORMS

You must complete this entire form. Do not skip any questions. Your answers help us to determine your health needs and what you qualify for. Return completed pages 3a & 3b back to Ansari HealthShare.

STEP 4- PAGE 4a & 4b- MEDICAL HISTORY EXPLANATION FORMS

Fill out these forms , and make a copy of 4b if you need more space for your explanations. Return 4a & 4b completed forms back to Ansari Healthshare.

STEP 5- PAGE 5- HIPPA FORM

Please read and sign this form at the top and at the bottom. Make sure to make a copy for your records. Return Completed page 5 back to Ansari Healthshare.

STEP 6- PAGE 6- JANAZA (BURIAL ASSISTANCE/ FINAL EXPENSE)

Complete the needed information on this form and sign. Make certain to put the names and phones numbers of the people you selected to manage your burial expenses for Janaza, IA. Return Completed page 6 back to Ansari Healthshare.

STEP 7- PAGE 7-PROGRAMS OPTIONS 7a- PAYMENTS 7b- AUTO WITHDRAWALS

STEP 8-PAGE 8-AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION

This release authorizes Ansari Healthshare, Inc.sm to use or disclose your Health Information. It’s important to complete all the information on these forms and submit your application processing fee at this time and return to Ansari HealthShare.

STEP 10 – EMPLOYERS ONLY – COMPLETE ALL FORMS ABOVE (SKIP STEP 7)
PAGE 10 – PROGRAMS OPTIONS 10a- PAYMENTS 10b- AUTO WITHDRAWALS

Email all forms back to enrollment@ansarihealthshare.com or upload to Ansari HealthShare.

You can also mail in your enrollment forms! See our mailing address at the Bottom of our Website. Any Questions call Customer service at (704) 900-8450. Our Operators are standing by!!

Ansari will process your applications and contact you. Make sure that we have your current email, phone number and address. By submitting your enrollment application, you are giving Ansari Healthshare permission to contact you using your email, phone or by mail. Unite with the many Muslims who are benefiting from affordable healthcare from Ansari HealthShare!