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AK, CO, CT, DC, HI, ME, MD, MA, MT, NH, NM, NY, ND, OR, PA, PR, SD, TX, VT, VA, WA, WY

Application Fee
$100.00 one-time
Product
$0.00 per Month for Individual
$0.00 per Month for Family
$0.00 per Month for Individual plus 1 Dependent

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Trinity HealthShare Programs Disclosures

THIS IS NOT A CONTRACT OR AN INSURANCE PRODUCT.

OVERVIEW

This is a voluntary program offered by Trinity Healthshare, Inc., a Health Care Sharing Ministry (HCSM). An HCSM is a group of individuals who share a common set of ethical or religious beliefs and voluntarily choose to share in the payment of their medical expenses in accordance with those beliefs, without regard to the state in which a member resides or is employed. Membership cannot be transferred to anyone other than the member and his/her eligible enrolled dependents.

Services are offered on a faith-based tradition of mutual aid, neighborly assistance, and burden sharing. Trinity is specifically tailored for individuals who maintain a healthy lifestyle, make responsible choices regarding health and care, and believe in helping others. As an HCSM, Trinity does not subsidize self-destructive behaviors or lifestyles. Trinity is NOT insurance and provides no guarantee to pay.

All Trinity HealthShare (Trinity) members are required to declare their acknowledgment of the Statement of Beliefs and to attest that they are of like mind with those beliefs.

STATEMENT OF BELIEFS

1. We believe that our personal rights and liberties originate from God and are bestowed on us by God.
2. We believe every individual has a fundamental religious right to worship God in his or her own way.
3. We believe it is our moral and ethical obligation to assist our fellow man when he/she is in need according to our available resources and opportunity.
4. We believe it is our spiritual duty to God and our ethical duty to others to maintain a healthy lifestyle and avoid foods, behaviors or habits that produce sickness or disease to ourselves or others.
5. We believe it is our fundamental right of conscience to direct our own healthcare, in consultation with physicians, family or other valued advisors.

DISCLAIMER; NO PROMISE TO PAY

Trinity HealthShare (Trinity) is a Health Care Sharing Ministry (HCSM), not an insurance company, and does not offer any insurance products or policies. As such, Trinity does not assume any risk for medical expenses and makes no promise to pay. Trinity offers voluntary participation in its HCSM programs, which are not governed by insurance laws.

Trinity does not provide a promise to pay or any guarantee of payment for medical expenses. Since Trinity does not assume the member’s risk, the member is responsible for payment of his/her medical bills. Trinity does not guarantee that medical expenses will be shared by other members who utilize the health care sharing services provided by Trinity.

VOLUNTARY PARTICIPATION

Trinity members are voluntary participants of an HCSM program. Enrollment, membership and participation in a Trinity HCSM program, such as the sharing of monetary contributions, is voluntary. Enrollment is not a contract. Members are free to withdraw participation at any time. Trinity requests a “monthly contribution” amount to be collected from members to facilitate the sharing of eligible medical expenses.

GUIDELINES

Trinity manages contributions by establishing the guidelines that generally define the sharing of eligible expenses between members of the Trinity HCSM (“Guidelines”), and more specifically defines the sharing of eligible expenses between members of each Trinity program outlined in the individual member guide(s) provided at the time of enrollment. The Guidelines and Trinity member guides are not contracts and do not constitute an agreement, a promise to pay, or an obligation to share.

The Guidelines are intended to ensure that every member has paid his/her own medical expenses as they are financially able before requesting others to share in the cost of remaining eligible medical expenses. The Guidelines generally define when a member is eligible for sharing requests, while individual member guide(s) detail what type of expenses may be eligible for sharing per program, including specific limitations, exclusions and requirements for sharing eligibility, so all members can expect a reasonable and equitable level of sharing. The amounts of sharing requests will be published monthly in a newsletter to members.

Trinity programs may exclude or have sharing limitations for pre-existing conditions. Members are required to fully disclose pre-existing conditions as part of their enrollment in Trinity programs. Trinity reserves the right, on behalf of members, to exclude sharing eligibility for any pre-existing conditions, whether disclosed at the time of enrollment or discovered after the effective date of membership. Furthermore, a member is not eligible for sharing when a member (i) receives care within the first 60 days of the program and cancels membership within 30 days of receiving medical care, except within the last 90 days of the membership term, or (ii) receives or requires surgery within the first 60 days of becoming a member, except in the case of an accident.

Trinity reserves the right to make updates to the Guidelines and member guides at any time on behalf of its HCSM program members. The Guidelines and member guides in effect at the time of service will supersede all previous versions of the Guidelines and member guides. Members will be notified of updates.

SHARING REQUESTS AND USE OF FUNDS

After receiving an eligible sharing request from a member or a provider, Trinity HealthShare will assign the eligible expense(s) for sharing, less the amount of personal responsibility required, called the Member Shared Responsibility Amount (MSRA).

Voluntary “monthly contributions” are received from each member, each month. Up to 30% of membership contributions may be applied towards administration of Trinity HealthShare programs, charitable causes, or general overhead costs. This does not include distribution compensation. Administrative costs are subject to change by Trinity HealthShare and may be applied towards other charitable causes or general overhead costs.

HCSM TAX MATTERS

Members should always consult with a tax professional to determine whether participation will have tax implications.

SPECIFIC PROGRAM DISCLOSURES

Please refer to program member guides for specific details about contributions, expenses eligible for sharing per program, limitations, exclusions and requirements for sharing eligibility: http://guides.trinityhealthshare.org/.

AUTHORIZATIONS

• I authorize Trinity HealthShare to collect the monthly contribution amount as a recurring monthly transaction.
• I authorize the monthly contribution amount to be processed immediately upon completion of my enrollment.

ACKNOWLEDGMENT

• I understand that the enrollment fee will be refunded automatically if all individuals on my enrollment form fail to attest to the Trinity Statement of Beliefs or if I withdraw my enrollment prior to my membership effective date.
• I understand that the enrollment fee will not be refunded if, in the course of enrolling, I fail to respond to written or verbal inquiries from Trinity for more than sixty days.
• I understand that I have requested voluntary participation in a Trinity HCSM program.
• I understand Trinity has the authorization to contact providers to request the release of medical records on behalf of the member.
• I affirm that the name and personal information provided on this form are true and correct.
• I affirm that I understand and accept the disclosures presented above.
• I understand that Trinity HealthShare, Inc. and its affiliates have the authority, under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), to request your medical records to facilitate the sharing of medical expenses.

STATE LEGAL NOTICES

LEGAL NOTICES

The following legal notices are required by state law, and are intended to notify individuals that health care sharing ministry programs are not insurance, and that the ministry does not provide any guarantee or promise to pay your medical expenses.

GENERAL LEGAL NOTICE

This organization facilitates the sharing of medical expenses but is not an insurance company, and neither its guidelines nor program of operation is an insurance policy. Sharing is available for all eligible medical expenses; however, this program does not guarantee or promise that your medical bills will be paid or assigned to others for payment. Whether anyone chooses to pay your medical bills will be totally voluntary. As such, this program should never be considered as a substitute for an insurance policy. Whether you or your provider receive any payments for medical expenses and whether or not this program continues to operate, you are always liable for any unpaid bills. This health care sharing ministry is not regulated by the State Insurance Departments. You should review this organization’s guidelines carefully to be sure you understand any limitations that may affect your personal medical and financial needs.

STATE SPECIFIC NOTICES

Alabama Code Title 22-6A-2

Notice: The organization facilitating the sharing of medical expenses is not an insurance company, and neither its guidelines nor program of operation is an insurance policy. Whether anyone chooses to assist you with your medical bills will be totally voluntary because no other participant will be compelled by law to contribute toward your medical bills. As such, participation in the organization or a subscription to any of its documents should never be considered to be insurance. Regardless of whether you receive any payment for medical expenses or whether this organization continues to operate, you are always personally responsible for the payment of your own medical bills.

Arizona Statute 20-122

Notice: The organization facilitating the sharing of medical expenses is not an insurance company and the ministry’s guidelines and program of operation are not an insurance policy. Whether anyone chooses to assist you with your medical bills will be completely voluntary because participants are not compelled by law to contribute toward your medical bills. Therefore, participation in the ministry or a subscription to any of its documents should not be considered to be insurance. Regardless of whether you receive any payment for medical expenses or whether this ministry continues to operate, you are always personally responsible for the payment of your own medical bills.

Arkansas Code 23-60-104.2

Notice: The organization facilitating the sharing of medical expenses is not an insurance company and neither its guidelines nor program of operation is an insurance policy. If anyone chooses to assist you with your medical bills, it will be totally voluntary because participants are not compelled by law to contribute toward your medical bills. Participation in the organization or a subscription to any of its documents should never be considered to be insurance. Regardless of whether you receive a payment for medical expenses or if this organization continues to operate, you are always personally responsible for the payment of your own medical bills.

Florida Statute 624.1265

Trinity HealthShare, Inc. is not an insurance company, and membership is not offered through an insurance company. Trinity HealthShare, Inc. is not subject to the regulatory requirements or consumer protections of the Florida Insurance Code.

Georgia Statute 33-1-20

Notice: The organization facilitating the sharing of medical expenses is not an insurance company, and neither its guidelines nor program of operation is an insurance policy. Whether anyone chooses to assist you with your medical bills will be totally voluntary because no other participant will be compelled by law to contribute toward your medical bills. As such, participation in the organization or a subscription to any of its documents should never be considered to be insurance. Regardless of whether you receive any payment for medical expenses or whether this organization continues to operate, you are always personally responsible for the payment of your own medical bills.

Idaho Statute 41-121

Notice: The organization facilitating the sharing of medical expenses is not an insurance company, and neither its guidelines nor program of operation is an insurance policy. Whether anyone chooses to assist you with your medical bills will be totally voluntary because no other participant will be compelled by law to contribute toward your medical bills. As such, participation in the organization or a subscription to any of its documents should never be considered to be insurance. Regardless of whether you receive any payment for medical expenses or whether this organization continues to operate, you are always personally responsible for the payment of your own medical bills.

Illinois Statute 215-5/4-Class 1-b

Notice: The organization facilitating the sharing of medical expenses is not an insurance company, and neither its guidelines nor program of operation constitute or create an insurance policy. Any assistance you receive with your medical bills will be totally voluntary. As such, participation in the organization or a subscription to any of its documents should never be considered to be insurance. Whether or not you receive any payments for medical expenses and whether or not this organization continues to operate, you are always personally responsible for the payment of your own medical bills.

Indiana Code 27-1-2.1

Notice: The organization facilitating the sharing of medical expenses is not an insurance company, and neither its guidelines nor its program of operation is an insurance policy. Any assistance you receive with your medical bills will be totally voluntary. Neither the organization nor any other participant can be compelled by law to contribute toward your medical bills. As such, participation in the organization or a subscription to any of its documents should never be considered to be insurance. Whether or not you receive any payments for medical expenses and whether or not this organization continues to operate, you are always personally responsible for the payment of your own medical bills.

Kentucky Revised Statute 304.1-120 (7)

Notice: Under Kentucky law, the religious organization facilitating the sharing of medical expenses is not an insurance company, and its guidelines, program of operation, or any other document of the religious organization do not constitute or create an insurance policy. Participation in the religious organization or a subscription to any of its documents shall not be considered insurance. Any assistance you receive with your medical bills will be totally voluntary. Neither the organization nor any participant shall be compelled by law to contribute toward your medical bills. Whether or not you receive any payments for medical expenses, and whether or not this organization continues to operate, you shall be personally responsible for the payment of your medical bills.

Louisiana Revised Statute Title 22-318,319

Notice: The ministry facilitating the sharing of medical expenses is not an insurance company. Neither the guidelines nor the program of operation of the ministry constitutes an insurance policy. Financial assistance for the payment of medical expenses is strictly voluntary. Participation in the ministry or a subscription to any publication issued by the ministry shall not be considered as enrollment in any health insurance program or as a waiver of your responsibility to pay your medical expenses.

Maine Revised Statute Title 24-A, §704, sub-§3

Notice: The organization facilitating the sharing of medical expenses is not an insurance company and neither its guidelines nor program of operation is an insurance policy. Whether anyone chooses to assist you with your medical bills will be totally voluntary because no other participant will be compelled by law to contribute toward your medical bills. Participation in the organization or a subscription to any of its documents should never be considered to be insurance. Regardless of whether you receive payment for medical expenses or whether this organization continues to operate, you are always personally responsible for the payment of your own medical bills.

Mississippi Title 83-77-1

Notice: The organization facilitating the sharing of medical expenses is not an insurance company, and neither its guidelines nor program of operation is an insurance policy. Whether anyone chooses to assist you with your medical bills will be totally voluntary because no other participant will be compelled by law to contribute toward your medical bills. As such, participation in the organization or a subscription to any of its documents should never be considered to be insurance. Regardless of whether you receive any payment of medical expenses or whether this organization continues to operate, you are always personally responsible for the payment of your own medical bills.

Missouri Section 376.1750

Notice: This publication is not an insurance company nor is it offered through an insurance company. Whether anyone chooses to assist you with your medical bills will be totally voluntary, as no other subscriber or member will be compelled to contribute toward your medical bills. As such, this publication should never be considered to be insurance. Whether you receive any payments for medical expenses and whether or not this publication continues to operate, you are always personally responsible for the payment of your own medical bills.

Nebraska Revised Statute Chapter 44-311

IMPORTANT NOTICE. This organization is not an insurance company, and its product should never be considered insurance. If you join this organization instead of purchasing health insurance, you will be considered uninsured. By the terms of this agreement, whether anyone chooses to assist you with your medical bills as a participant of this organization will be totally voluntary, and neither the organization nor any participant can be compelled by law to contribute toward your medical bills. Regardless of whether you receive payment for medical expenses or whether this organization continues to operate, you are always personally responsible for the payment of your own medical bills. This organization is not regulated by the Nebraska Department of Insurance. You should review this organization’s guidelines carefully to be sure you understand any limitations that may affect your personal medical and financial needs.

New Hampshire Section 126-V:1

IMPORTANT NOTICE:This organization is not an insurance company, and its product should never be considered insurance. If you join this organization instead of purchasing health insurance, you will be considered uninsured. By the terms of this agreement, whether anyone chooses to assist you with your medical bills as a participant of this organization will be totally voluntary, and neither the organization nor any participant can be compelled by law to contribute toward your medical bills. Regardless of whether you receive payment for medical expenses or whether this organization continues to operate, you are always personally responsible for the payment of your own medical bills. This organization is not regulated by the New Hampshire Insurance Department. You should review this organization’s guidelines carefully to be sure you understand any limitations that may affect your personal medical and financial needs.

North Carolina Statute 58-49-12

Notice: The organization facilitating the sharing of medical expenses is not an insurance company and neither its guidelines nor its program of operation is an insurance policy. Whether anyone chooses to assist you with your medical bills will be voluntary. No other participant will be compelled by law to contribute toward your medical bills. As such, participation in the organization or a subscription to any of its documents should never be considered to be insurance. Regardless of whether you receive any payment for medical expenses or whether this organization continues to operate, you are always personally liable for the payment of your own medical bills.

Pennsylvania 40 Penn. Statute Section 23(b)

Notice: This publication is not an insurance company nor is it offered through an insurance company. This publication does not guarantee or promise that your medical bills will be published or assigned to others for payment. Whether anyone chooses to pay your medical bills will be totally voluntary. As such, this publication should never be considered a substitute for insurance. Whether you receive any payments for medical expenses and whether or not this publication continues to operate, you are always liable for any unpaid bills.

South Dakota Statute Title 58-1-3.3

Notice: The organization facilitating the sharing of medical expenses is not an insurance company, and neither its guidelines nor program of operation is an insurance policy. Whether anyone chooses to assist you with your medical bills will be totally voluntary because no other participant will be compelled by law to contribute toward your medical bills. As such, participation in the organization or a subscription to any of its documents should never be considered to be insurance. Regardless of whether you receive any payments for medical expenses or whether this organization continues to operate, you are always personally responsible for the payment of your own medical bills.

Texas Code Title 8, K, 1681.001

Notice: This health care sharing ministry facilitates the sharing of medical expenses and is not an insurance company, and neither its guidelines nor its program of operation is an insurance policy. Whether anyone chooses to assist you with your medical bills will be totally voluntary because no other participant will be compelled by law to contribute toward your medical bills. As such, participation in the ministry or a subscription to any of its documents should never be considered to be insurance. Regardless of whether you receive any payment for medical expenses or whether this ministry continues to operate, you are always personally responsible for the payment of your own medical bills. Complaints concerning this health care sharing ministry may be reported to the office of the Texas attorney general.

Virginia Code 38.2-6300-6301

Notice: This publication is not insurance, and is not offered through an insurance company. Whether anyone chooses to assist you with your medical bills will be totally voluntary, as no other member will be compelled by law to contribute toward your medical bills. As such, this publication should never be considered to be insurance. Whether you receive any payments for medical expenses and whether or not this publication continues to operate, you are always personally responsible for the payment of your own medical bills.

Wisconsin Statute 600.01 (1) (b) (9)

ATTENTION:This publication is not issued by an insurance company, nor is it offered through an insurance company. This publication does not guarantee or promise that your medical bills will be published or assigned to others for payment. Whether anyone chooses to pay your medical bills is entirely voluntary. This publication should never be considered a substitute for an insurance policy. Whether or not you receive any payments for medical expenses, and whether or not this publication continues to operate, you are responsible for the payment of your own medical bills.

Trinity HealthShare programs are not available in AK, CO, CT, HI, MA, MD, ME, MT, ND, NH, NM, NY, OR, PA, PR, SD, TX, VA, VT, WA, WY or Washington, D.C. Limitation subject to change without prior notice. Due to regulatory limitations regarding compensation, Trinity HealthShare programs will no longer be sold in Massachusetts or Pennsylvania.

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© Trinity Healthshare, Inc. All rights reserved.

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