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Testimony & Commitment

Name:Dawn Jordan CCM ID#:18208100 Date Submitted:07/29/2015
Do you agree with our Statement of Faith below (Medi-Share Guidelines, Section II.A.) ?

All adult members (18 years of age or older) must have a verifiable Christian testimony indicating a personal relationship with the Lord Jesus Christ and profess to the following Statement of Faith:

  • I believe that there is only one God (Deuteronomy 6:4) eternally existing in three Persons: the Father, Jesus Christ the Son, and the Holy Spirit (Matthew 28:19). I believe Jesus is God, in equal standing with the Father and the Holy Spirit (Colossians 1:15-20, 2:9).
  • I believe the Bible is God’s written revelation to man and is verbally inspired, authoritative, and without error (2 Timothy 3:16-17).
  • I believe in the deity of Jesus Christ -- who existed as God before anything was created (John 1:1), His virgin birth (Matthew 1:23), sinless life (Hebrews 4:15), miracles, death on the cross to provide for our redemption (1 Peter 2:24), bodily resurrection and ascension into heaven (1 Corinthians 15:3-8), present ministry of intercession for us (Hebrews 7:24-25) and His return to earth in power and glory (Matthew 24:30). He is the world’s only Savior and is the Lord of all (John 14:6, Acts 4:12, Isaiah 45:21-23).
  • I believe in the personality and deity of the Holy Spirit (Acts 5:3-4), that He performs the miracle of new birth in an unbeliever and indwells believers (1 Corinthians 3:16), enabling them to live a godly life (Romans 8:14).
  • I believe man was created in the image of God, but because of sin was alienated from God. Alienation can be removed only by accepting God’s gift of salvation by grace through faith (Ephesians 2:8-10) which was made possible by Christ’s death and resurrection. This faith will be evidenced by the works that we do (James 2:17, 26).
I agree
Do you agree with the following?
  • That sin has separated man from God.
  • That the Bible teaches that all have sinned and come short of the glory of God.
  • That our sin is forgiven only through faith in Christ and his atonement for our sin.
  • By believing in Christ and his atonement we are forgiven from all our sin.
  • Our relationship with the Lord is because of His grace and mercy.
  • The belief in Jesus Christ is the only way to salvation and eternity in heaven.
  • That the evidence of our faith in Christ will be seen by changed life and works that glorify the Father.
Yes
Do you have a personal relationship with Jesus Christ?
Yes
Do you have a place where you are consistently being taught the Bible?
Yes
What is your denomination?
Baptist
Affordable Care Act Acknowledgement

I understand that compliance with the Affordable Care Act requires that I must either be an active member of a health care sharing ministry or have purchased a qualified health plan. I understand that I can only purchase a qualified health plan during an open enrollment period. I understand that if I stop my Medi-Share participation for whatever reason, including voluntarily or if my participation is placed in inactive status due to a failure to share or follow the Medi-Share Guidelines, that I will not be in compliance with the Affordable Care Act.

If my participation in Medi-Share ends outside of the open enrollment period and I am not able to purchase a qualified health plan, I understand that I will be subject to the law's penalty for each month that I am not either enrolled in a qualified health plan or am a member of a health care sharing ministry. I also understand that the same penalties shall apply to anyone in my family who participates in Medi-Share through my membership who is also required to either be enrolled in a qualified health plan or be a member of a health care sharing ministry.

I Understand
Authorization for Release of Protected Health Information

1. I authorize the disclosure of protected health information, including but not limited to, medical records, reports, medical bills, pharmaceutical records, diagnostic test results, and lab test results.

2. I understand that the following parties will receive this information regarding my membership in the sharing program: Christian Care Ministry, Inc. (“CCM”), its employees and authorized agents.

3. Those parties that receive protected health information may disclose it for purposes of treatment, payment, or operations of Medi-Share. They may otherwise disclose information only as allowed or authorized by law. These parties include insurers to which proposed member has applied or may apply, pharmacy benefit managers, physicians, hospitals, clinics or other medical related facilities, health care clearing houses or persons who perform tasks for them.

4. I understand that this protected health information is needed to verify eligibility of my bills submitted to CCM.

5. Unless revoked earlier, this authorization will be valid as long as I am enrolled in Medi‐Share plus 18 months from the date my membership ends.

6. I understand that I may revoke this authorization at any time by notifying CCM in writing at P.O. Box 120099, West Melbourne, FL 32912, but if I do, it won't have any effect on any actions taken prior to receiving the revocation.

7. I understand that this authorization is voluntary; I understand that I may get a copy of this form after signing it.

8. I understand that if an organization I authorize to receive the protected health information is not a health plan or healthcare provider, federal or state law may no longer protect the released information and it will no longer be private.

I Understand and Agree
By joining Medi-Share, I understand and agree to the following:
  1. I have carefully read and commit to abide by all provisions stated in the Medi-Share Guidelines. All persons listed on this form believe that the body is the temple of the Holy Spirit, to be kept pure and as such:
    • I do not engage in sex outside of traditional Biblical marriage, which is a union of one man and one woman. (Gen.2:22-24, Mat. 19:5, Eph. 5:22-32)
    • I do not and will not use tobacco in any form or illegal drugs and have not for the last 12 months.
    • I agree not to abuse legal drugs, including alcohol and have not abused them for the past 12 months.
    • I understand that when any member of the family chooses not to live by these principles, I have a responsibility to notify CCM. I also realize the family member may no longer qualify to participate in Medi- Share and their membership will be cancelled and his or her bills will not be eligible for sharing.
  2. I understand that Christian Care Ministry, Inc. (CCM) matches a Medi-Share member’s medical bills with other members who have volunteered, in faith, to share in meeting needs through the biblical concept of Christian mutual sharing. I realize and accept that all money comes from the voluntary giving of Medi-Share members, not from CCM, and that CCM does not pay nor is it liable for the payment of any medical bills.
  3. Each month I will be notified in advance of the fellow Christian who will be receiving my gift toward their medical bills. I will endeavor to pray for and encourage this member in writing. Similarly, I understand that when I have a medical bill published for sharing, my information, including email and/or mailing address, will be available online on the secure member website for fellow members to pray for and encourage me.
  4. I understand that in order to determine the eligibility of the medical bills for sharing when an illness or injury occurs, medical records may be required from providers who have diagnosed or treated the member. I understand and agree that no medical bill will be shared if authorization for obtaining such medical records is withheld.
  5. I consent to the recording of all telephone calls to or from CCM.
  6. I agree that in cases where all administrative appeals have been exhausted and after an appeal process, any and all remaining disputes will be settled solely as follows: by biblically-based mediation, not in a secular court. If resolution of the dispute and reconciliation does not result from mediation, the matter shall then be submitted to an independent and objective arbitrator for binding arbitration. I agree that suing fellow Christians, including Christian ministries, is contrary to scripture (1Cor. 6:1-8); therefore, I will bring no suit, legal claim or demand of any sort against CCM in the civil court system, with the sole exception of enforcing any favorable arbitration award or mediated agreement.
  7. I understand that any false statements on or omissions from this form, the Application for the Medi-Share Program or at any time during my participation in Medi-Share will be cause for cancellation of my Medi-Share membership. I understand that there is limited sharing during the first month of membership.
I Understand and Agree
If I am accepted into the Medi-Share program my one-time Medi-Share fee of $120 will be due with my first month's share. This does not apply to Senior Assist, Add-On or an applicant leaving family membership for individual membership. A one-time fee of $5 will also be due for my ACCU membership fee, unless I am an Add-On applicant.
I Understand and Agree
Signature
I declare that the information contained herein is complete and true to the best of my knowledge.
Agreement terms and conditions accepted and signed by Dawn Jordan.

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