MediShareQuestionnaire
Date
RequiredDate
HowManyFamilyMembers
CompanyPlanMoPmt
MS
HV
TM
SGH
BCBS
STP
Dental
Vision
PrimaryName
PN-SSNumber
PN-Birthday
SpouseName
Spouse-SSNumber
SpouseBirthday
Child1Name
Child1SocialSecurityNumber
Child1Birthday
Child2Name
Child2SocialSecurityNumber
Child2Birthday
Child3Name
Child3SocialSecurityNumber
Child3Birthday
Child4Name
Child4Birthday
Child4SocialSecurityNumber
Child5Name
Child5Birthday
Child5SocialSecurityNumber
YES-NO-TobaccoUsedWithin12months
AnyPreExistingMedicalIssues
StreetNumber
StreetName
CityStateZipCode
PhoneNumber
EMailAddress
VisaMCDiscover
CardNumber
SecurityCode
ExpirationDate
BillingAddressForCreditCard
YESNOIUnderstandThereIsA50ApplicationFee
YESNOIUnderstandMediShareIsNotInsuranceAndChristianCareMinistryDoesNotGuaranteePaymentOfAnyMedicalBi
YESNOIUnderstandThatNoMediShareMembernorCCMHasAnyLegalObligationtoContributeToThePmtOAnyfMedicalBill
Note1
Note2
Note3
Let's Go!
Another place to add text here!