Enrollment Form – Anglican Care Portal

Applicant Information

First Name *

Last Name *

Date of Birth *

Gender *

Marital Status *

SSN (Last 4) *

Street Address *

Address Line 2

City *

State *

ZIP Code *

Phone *

Email Address *

Occupation

Employer

Spouse Information

Spouse Full Name

Spouse Date of Birth

Spouse SSN (Last 4)

Spouse Phone

Dependents (up to 5)

Dependent 1

Full Name

Relationship

Date of Birth

Gender

Dependent 2

Full Name

Relationship

Date of Birth

Gender

Dependent 3

Full Name

Relationship

Date of Birth

Gender

Dependent 4

Full Name

Relationship

Date of Birth

Gender

Dependent 5

Full Name

Relationship

Date of Birth

Gender

Program Selection

Individual & Family Group & Organization Senior Care Catastrophic Add-On

Requested Enrollment Date *

Statement of Faith

Anglican Care is a faith-based health sharing ministry. Members share a common set of Christian beliefs. Please confirm your agreement with the following statements:

I believe in one God, Father, Son, and Holy Spirit, and confess Jesus Christ as my Lord and Savior. I believe the Bible is the inspired Word of God and the authoritative guide for faith and life. I believe in the sanctity of life from conception to natural death. I believe marriage is a covenant between one man and one woman as established by Scripture. I agree to live according to Christian principles and to support fellow members in prayer and care.

Applicant Signature

Signature (type full name) *

Date *

Health Information

Height (inches)

Weight (lbs)

Blood Type

Tobacco Use *

Alcohol Use

Pre-existing Conditions *

Pre-existing Conditions Description

Current Medications

Allergies

Emergency Contact

Emergency Contact Name *

Relationship

Emergency Contact Phone *

Emergency Contact Email

Primary Care Provider

Provider Name

NPI Number

Facility Name

Provider Phone

Provider Address

Provider Fax

Consent & Authorization

I agree to all of the above terms and conditions.

Signatures

Applicant Signature (type full name) *

Applicant Date *

Spouse Signature (type full name)

Spouse Date

Membership Start Date

Requested Start Date *

Program Level

“And let us consider how we may spur one another on toward love and good deeds.”

— Hebrews 10:24

Monthly Payment Method

ACH / Bank Transfer Credit / Debit Card Check by Mail

ACH Setup

Bank Name

Account Type

Routing Number

Account Number

Name on Account

Day of Month

Credit Card

Visa Mastercard Amex Discover

Card Number

Name on Card

Expiration (MM/YY)

CVV

Billing ZIP Code

Check by Mail

If you prefer to pay by check, please mail your monthly contribution to:

Anglican Care
P.O. Box 1000
Tyler, TX 75710

Please include your member code on the check. Your membership will be activated once the first payment is received.

Authorization

I authorize Anglican Care to process recurring monthly contributions using the payment method selected above until I cancel in writing. I confirm that all payment information provided is accurate and I am authorized to use this payment method.

Ministry Use Only

Member ID

Enrollment Date

Approved By

Program Assigned

Payment Set Up

Tier