2025 Ansari Health Share Enrollment Process Step 1 of 7 14% This field is hidden when viewing the formSection 1. Primary Applicant /Guardian InformationName(Required) Dr.MissMr.Mrs.Ms.Prof.Rev. Prefix First Middle Last Suffix Preferred NameDate of Birth(Required) MM slash DD slash YYYY Age Range(Required)18 – 2930 – 3940 – 4950 – 64Add a spouse?(Required) Yes No Add Dependents?012345678910+Email(Required) Phone(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country This field is hidden when viewing the formAdd Spouse Yes This field is hidden when viewing the formAdd Dependants Yes Section 2. Spouse InformationName(Required) First Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Birthdate (DOB):(Required) MM slash DD slash YYYY Age(Required)Section 3. Dependent InformationName(Required) First Last DOB:(Required) MM slash DD slash YYYY Age(Required)S. Security/GRN Card#:(Required)Name(Required) First Last DOB:(Required) MM slash DD slash YYYY Age(Required)S. Security/GRN Card#:(Required)Name(Required) First Last DOB:(Required) MM slash DD slash YYYY Age(Required)S. Security/GRN Card#:(Required)Name(Required) First Last DOB:(Required) MM slash DD slash YYYY Age(Required)S. Security/GRN Card#:(Required)Name(Required) First Last DOB:(Required) MM slash DD slash YYYY Age(Required)S. Security/GRN Card#:(Required)Name(Required) First Last DOB:(Required) MM slash DD slash YYYY Age(Required)S. Security/GRN Card#:(Required)Name(Required) First Last DOB:(Required) MM slash DD slash YYYY Age(Required)S. Security/GRN Card#:(Required) This field is hidden when viewing the formSection 2. Confirmation of AcknowledgementConfirmation of Acknowledgement(Required)– Two Month Waiting Period- I confirm that my sharing as a member doesn’t start until after 2 months or 60 days. Limitations do apply (see Guidelines). * Note; Ansari HealthShareSM reserves the right to approve or disapprove your membership and that you will receive a letter or email confirming this decision only after applying. We do accept some pre-ex-existing conditions, however, some conditions may not be approved – Enrollment Refund Fee- When a member, couple or members of a family found to be ineligible for membership, half of the initial enrollment fee will be refunded upon request, due to verification processing costs. If a Member is terminated retroactively due to a failure in disclosing all important and relevant medical information he may be eligible for a refund. However, any medical expenses shared with the member, will be deducted from the refundable amount. Members with certain health conditions such as high blood pressure, high cholesterol, and obesity may be required to participate in the Ansari HealthShareSM for an additional monthly charge of $50. If you are assigned to the Ansari HealthShareSM Wellness Program, and if you choose not to continue your membership, your application Fee may be refunded within 90 days of membership. – Monthly Contribution Confirmation- Monthly Share Contribution Amount is the amount you contribute or pay monthly for the program that you chose. This is determined by the household size. This does not include the initial enrollment fee or renewal Membership dues are likewise not included. – Discount Medicines- Ansari HealthShareSM does not supply medicines. We can only recommend or refer a medicine discount program and their coupons at this time. Sometimes we may be able to share some coupons with our members. – Guidelines Changes These Guidelines may be amended from time to time as circumstances require and as determined to be appropriate by a Ansari HealthShareSM Board of Directors and /or Ansari HealthShareSM administration. – Disclaimer This program is not an insurance company, nor is it offered through an insurance company or broker. This program does not guarantee or promise that your medical bills will be paid. Whether anyone chooses to pay your medical bills will be entirely voluntary. As such, this program should never be considered as a substitute for an insurance policy. Whether you receive any payments for medical expenses and whether or not this program continues to operate, you are always liable for any unpaid bills. * Note; Ansari HealthShareSM reserves the right to approve or disapprove your membership and that you will be contacted confirming this decision only after applying. We do not accept most preexisting conditions, however, some conditions that are managed well thru medicines may be approved for membership. With the understanding that your membership is conditional and must abide by our guidelines concerning your well being and condition. – Enrollment Refund Fee- When a member, couple or members of a family found to be ineligible for membership, half of the initial enrollment fee will be refunded upon request, due to verification processing costs. If a Member is terminated retroactively due to a failure in disclosing all important and relevant medical information he may be eligible for a refund. However, any medical expenses shared with the member, will be deducted from the refundable amount. Members with certain health conditions such as high blood pressure, high cholesterol, and obesity may be required to participate in the Ansari HealthShareSM for an additional monthly charge of $50. If you are assigned to the Ansari HealthShareSM Wellness Program, and if you choose not to continue your membership, your application Fee may be refunded within 90 days of membership. – Monthly Contribution Confirmation- Monthly Share Contribution Amount is the amount you contribute or pay monthly for the program that you chose. This is determined by the household size. This does not include the initial enrollment fee or renewal Membership dues are likewise not included. – Discount Medicines- Ansari HealthShareSM does not supply medicines. We can only recommend or refer a medicine discount program and their coupons at this time. Sometimes we may be able to share some coupons with our members. – Guidelines Changes These Guidelines may be amended from time to time as circumstances require and as determined to be appropriate by a Ansari HealthShareSM Board of Directors and /or Ansari HealthShareSM administration. – Disclaimer This program is not an insurance company, nor is it offered through an insurance company or broker. This program does not guarantee or promise that your medical bills will be paid. Whether anyone chooses to pay your medical bills will be entirely voluntary. As such, this program should never be considered as a substitute for an insurance policy. Whether you receive any payments for medical expenses and whether or not this program continues to operate, you are always liable for any unpaid bills. * Note; Ansari HealthShareSM reserves the right to approve or disapprove your membership and that you will be contacted confirming this decision only after applying. We do not accept most preexisting conditions, however, some conditions that are managed well thru medicines may be approved for membership. With the understanding that your membership is conditional and must abide by our guidelines concerning your well being and condition. I verify that I have read and agree to the above Confirmation of Acknowledgements This field is hidden when viewing the formSection 3. Statement of AgreementStatement of Agreement(Required)1. Everyone has a right to choose their own religion without any compulsion. 2. To Live a healthy and God-fearing lifestyle 3. To do unto your neighbor as you would want done unto you. 4. I believe that a community of moral, ethical, and God-conscious people can encourage and care for one another by directly sharing the costs and medical expenses associated with each other. 5. I understand and agree that Ansari HealthShareSM is a Charitable and Nonprofit Organization. It is not an insurance program or entity, and while Ansar HealthShareSM assures that sincere effort will be put forth to have members fulfill their monthly sharing commitments, Ansari HealthShareSM, in and of itself, cannot guarantee payment of any health expenses. 6. I agree to practice a good and wholesome lifestyle. 7. I agree to strive to refrain from the using of any form of illicit/illegal drugs and alcohol usage, all of which are harmful to the body. (Tobacco users have an additional share payment of $50 monthly per household.) 8. I believe that I am obligated to care for my family and that physical, mental or emotional abuse to anyone and especially family members are prohibited, and to live a crime-free lifestyle. 9. I agree to join into mediation followed by subsequent binding arbitration, if needed, for any incident of a dispute with Ansari HealthShareSM or their affiliates. 10. I further believe that cooperation in the voluntarily monthly contributions for membership and application fee allows me to share in Ansari HealthShareSM programs if approved for enrollment. 11. I agree to accept and abide by Ansari HealthShare(sm) Guidelines and the program policies according to Ansari HS interpretations. And, that I have read and accept the terms and conditions of the privacy policy listed on AHS website. Note: Ansari HealthShare(sm) reserves the right to approve or disapprove your membership and that you will be contacted confirming this decision only after applying. I verify that I have read and agree to the above Statement of Agreements This field is hidden when viewing the formSection 4. Ansari Health Share OptionsPick a Plan(Required) Ansari Basic Ansari Premiere Ansari Supreme Choose Who Needs Coverage(Required) Member Only Member + Spouse Member + Child(ren) Member + Family For Monthly Contribution Cost click the link below and use our instant quote tool Instant Quote This field is hidden when viewing the formDue TodayEnrollment Fee Price: $100.00 There is an enrollment fee of $100 and $75 recurring annual fee thereafter. *Your monthly contribution will be invoiced to you after your enrollment application has been approved.Credit Card Δ
