Important Information for New Members
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- Erin Henry
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1 HEALTHCARE BY AMERICANS, FOR AMERICANS Important Information for New Members We are happy welcome you our caring, committed community for sharing medical costs. Your welcome packet contains helpful information for getting you started. If you have not yet received your membership cards in the mail, they will arrive shortly. You can log in your ShareBox through If you enrolled online you already have an Account. Use the address and password created when you enrolled and select Log In. If you did not enroll online select the Register option and follow the instructions. You will need your membership number complete your registration. Once you ve logged in your Member section of the website, you will land on your Sharebox page. This is where you will manage your profile and settings, as well as view your sharing hisry. If you signed up as a Plus or Complete member, you will also receive your discount cards from SavNet. These will come directly from them, and separate from your Liberty HealthShare member cards. Understanding how your bank or credit card statement will look is important. Each month LBRTYHLTHSHAR will appear on your statement. You may have already noticed that if your Annual Membership Dues were charged your credit or debit card. If you are a Liberty Plus or Liberty Complete member, that transaction includes your enrollment with SavNet. If you have chosen the option of aumatic approval for payments your transactions will occur on the 5 th of every month. If you have opted for manual approval please log in your ShareBox and select the red APPROVAL option by the 5 th of each month. You may also call process your payments. If you send a check, please make sure we receive it at the beginning of each month. Included in this packet are three forms that prompt you for your signature. Please read, sign and return the forms for LHS Member s Medical Expense Need Agreement and Authorization for Release of Medical Information as soon as possible. The Medical Expense Processing Form needs be filled out and sent us any time that you are submitting bills for either a medical need or prescription reimbursement. Our members are important us, so please do not hesitate call and ask questions any time! Welcome our caring, committed community! Drudy Abel Associate Direcr Liberty HealthShare Inc LIBERTY ( ) 4845 Fuln Dr. NW / Cann, OH / (855)58-LIBERTY /
2 Authorization for Release of Medical Information Member Name(s): (Please Print) Member Number: To facilitate appropriate utilization of medical resources with respect my health care needs, I am in agreement with participating in the medical expense adjudication program of Liberty HealthShare. I authorize the release and use by Liberty HealthShare, or any designee action on the company s behalf, of any personal, medical and employment related information for myself or on behalf of my eligible dependents. This information may be released by my attending physician or other medical and non medical professionals who have been involved in my care. I understand that the intent of this authorization secure information is solely for the purpose of case management, adjudication and pricing of my medical expenses, if appropriate. I authorize that this information may be shared with other professionals, agencies or insurance companies who may be involved in the provision or payment of necessary services. Such disclosure will be limited release of information necessary the management of my medical care and payment of my medical expenses. I understand that I may withdraw this consent at any time except the extent that action has already been taken. A copy of this authorization may be accepted, if necessary. I understand that I may have a copy of this authorization if I request it. Signature of Individual or Authorized Representative Printed Name of Individual Signature of Spouse (if applicable Printed Name of Individual Date
3 HEALTHCARE BY AMERICANS, FOR AMERICANS LHS Member s Medical Expense Need Agreement I acknowledge that it would be a violation of the trust placed in me by my fellow members within the Liberty HealthShare sharing community if I used the funds received for my medical expense need for any other reason than pay my medical bills. Therefore, I do hereby pledge, agree and commit, without reservation or intent deceive, only use the amounts donated my online, ShareBox account, reimburse my medical providers. I do also direct Liberty HealthShare cause those funds be disbursed, in the amounts, and according the schedule, so set by Liberty HealthShare, by means of payment, electronic or otherwise, the medical service providers last known address. Print Name: Authorized Signature: Member Number: Date: 4845 Fuln Dr. NW / Cann, OH / (855)58-LIBERTY /
4 Medical Expense Processing Form Return form : Liberty HealthShare Contact Us: Toll Free: Fuln Dr. NW Cann, OH Fax: Info@LibertyHealthShare.org Instructions: Please read and complete. MEMBER INFORMATION Member Number: Primary Member Name: Address: Home Phone: Work Phone: Cell Phone: Address: PATIENT INFORMATION Patient Name: Date of Birth: / / Age: PREVIOUS CONDITIONS Did you have signs, sympms, or treatment of this condition before joining LHS? Yes No MATERNITY ONLY Expected due date: / / Actual birth date: / / ACCIDENTS ONLY Accident Type: Au Other (Specify): INCIDENT OR ILLNESS DESCRIPTION (Please provide a brief explanation of the incident or illness) I attest that all information provided herein is true and correct the best of my knowledge. Signature: Date:
5 LIBERTY REWARDS PROGRAM Refer. Enroll. Earn Earn a $ Visa Gift Card for Each Referral that Enrolls! How does it work? 1. Refer your friends and family. 2. We ll contact and assist them. 3. When they enroll and are members for 60 days, you receive a $ Visa Gift Card! There is no limit! You can help us grow! Refer your friends and family day! FULL NAME PHONE NUMBER ADDRESS (Please feel free write additional contacts on the reverse side of flyer.) Your Name: Account Number: Earn a $ Visa gift Card for Each Referral that Enrolls! * Referrals provided Liberty HealthShare will be entered in our lead database. The individuals provided will be contacted by Liberty HealthShare or a contracted third party for the purpose of Liberty HealthShare program and services only Liberty HealthShare will not rent, sell or share the lead information any non Liberty HealthShare related companies. For an individual be eligible for rewards compensation the individual must be a current sharing member of Liberty HealthShare. The lead provided must enroll, be accepted and be an active sharing member that is current in their share amounts for two (2) months. Not available in PA or in other states where prohibited by law.
6 healthcare by americans, for americans MEDICAL COST SHARING SUMMARY Expenses Eligible for Sharing Liberty Liberty Plus Liberty Share Complete Annual Unshared Amount (-First dollar amount of annual medical costs not eligible for sharing)* Single Couple Family Annual Unshared Amount ()*: $500 $1000 $1500 Annual Unshared Amount ()*: $500 $1000 $1500 Annual Unshared Amount ()*: $500 $1000 $1500 *Note: The Annual Unshared Amount () is the amount of an eligible expense that does not qualify for sharing, and is calculated upon each member s enrollment date until their next annual enrollment date. Note: A Medical Expense Incident is the charge(s) incurred for eligible medical treatment arising from any illness or accident of a Sharing Member, and any fees incurred by Liberty HealthShare reduce such charges. All providers treating the same illness (diagnosis) are combined in the same incident. Maximum Eligible Sharing Limit Per Incident Single Couple Family ** **Guardians Group is an optional sharing program of Liberty HealthShare for catastrophic expense needs up and requires separate enrollment and monthly financial participation. Note: The following expenses will not apply ward the maximum expense limit: (1) Reduced share amount for failure follow Health Care Management procedures. (2) Any charge excluded in the Sharing Guidelines. (3) Any other charges that exceed maximum Limits. Lifetime Maximum Amount NONE Pre-Notification: STEP ONE: The Pre-Notification staff must be notified of the following services before occurrence: All inpatient Confinements (including Hospital, Skilled Nursing, Inpatient Rehabilitation Facility and Hospice Care) Emergency Admission (within 48 hours) Pregnancy/Maternity Organ/Tissue Transplant Services Home Healthcare Services Outpatient Surgery STEP ONE: Call Pre-Notification at STEP TWO: Contact Cusmer LIBERTY ( ) verify eligibility of charges. Charges will be ineligible for sharing if timely notification is not received for all charges for rendered services listed above. Pre-Notification (Step One above) does not guarantee that your expenses will be shared. Please contact Cusmer Service verify eligibility for sharing. Accidents (Accidents are investigated for other party liability) Ambulance Services Chiropractic Services Limit 12 visits per Calendar Year Diagnostic X-ray and Laborary Services Inpatient Outpatient Independent Lab (Outside Lab) Emergency Room Hospital and Physician Services (Routine treatment excluded) 4845 Fuln Dr. N.W. Cann, OH (855) 58-LIBERTY After 70% up after
7 healthcare by americans, for americans MEDICAL COST SHARING SUMMARY Home Health Care Expenses Eligible for Sharing Limit 30 days per Incident Hospital Services Inpatient Daily Room and Board limited the average semiprivate room rate. Outpatient Maternity Care Normal delivery (including Physician Charges, Office Visits, Hospital Charges and Birthing Centers) Cesarean Section and/or Complications treated as new incident with new per incident limits. Physician Office Services Per incident visit All other Physician office services included per incident. (Charges billed by a Physician if performed in the Physician s office: injection, surgery, lab, x-ray, special diagnostic interpretation.) Prescription Drugs Per incident (Charges must occur within 45 days before or after any related medical incident) Preventative Screenings Mammograms, PSA tests, Screening colonoscopies Limit: 1 every 2 years;1 per year over 50 Surgery Surgeon, assistant surgeon and anesthesiologist services Inpatient Services Outpatient Services Outpatient Surgery Facility Therapy Limit 20 visits per Calendar Year (Combined with Speech, Respirary, Physical, Occupational Therapy) Wellness Babies 0-1yr All well baby checkups including vaccinations Adults 1yr+ - Includes labs, x-rays (1 per Membership Year) All Other Eligible Expenses (Unless limited by Sharing Guidelines) Liberty Complete 100% up after after Not Subject 100% up Not Subject after Liberty Plus After Not Subject Not Subject after Liberty Share Not Subject Not Subject after 4845 Fuln Dr. N.W. Cann, OH (855) 58-LIBERTY
8 Provider Nomination Member Name: Member ID Number: Please nominate your providers, and we will contact them be on our recommended providers list. Established patient with Docr or Provider? Yes or No Established patient with Docr or Provider? Yes or No Established patient with Docr or Provider? Yes or No Established patient with Docr or Provider? Yes or No Established patient with Docr or Provider? Yes or No Please Fax : with Attn: Provider Relations OR providerrelations@libertyhealthshare.org
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