How do you plan on using this form today.How do you plan on using this form today?* Adding An Employee Removing An Employee Updating An Existing Member/Employee Information Company InformationCompany Name* Company Email Membership ID Plan SelectionSelect Plan Information* Coverage TierEmployee OnlyEmployee & SpouseEmployee & Child(ren)Employee & Family Oldest Age in Family Tobacco Usage? Plan Selection Preventive Sharing Rx Share Teladoc LifeWorks Total Employee Contact InformationPhone*Extension Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Member InformationMember Information*Important: Fields do not validate. Please enter the primary account holder's information first. Please enter Relationship as self, spouse, or child. Enter date of birth using mm/dd/yyyy format. Please enter tax ID using xxx-xx-xxxx format. Use the "+" button on right side to add additional dependents.First NameLast NameRelationshipDate of BirthGenderTobacco User (Y/N) Termination DateTermination DateNovember 1st, 2022December 1st, 2022January 1st, 2023February 1st, 2023March 1st, 2023April 1st, 2023Please select which month you would like your enrollment to terminate.Medical Conditions Existing Prior to MembershipNeeds that result from a condition that existed prior to membership are only shareable if the condition is fully cured and 24 months have passed without any symptoms, treatment, or medication, even if the cause of the symptoms is unknown or misdiagnosed.Member NameConditionLast Treatment Date Needs that result from a condition that existed prior to membership are only shareable if the condition is fully cured and 24 months have passed without any symptoms, treatment, or medication, even if the cause of the symptoms is unknown or misdiagnosed.Member AgreementOur Agreements* I have read and agree to the Zion HealthShare Member Guidelines, including the Principles of Membership, limitations on pre-existing conditions, and the tobacco policy. Request Effective MonthRequest Effective MonthNovember 1st, 2022December 1st, 2022January 1st, 2023February 1st, 2023March 1st, 2023April 1st, 2023May 1st, 2023Effective dates are the first of the selected month. We try to accommodate requested effective dates the best we can though there are sometimes limitations with the carrier providing coverage. We cannot back date coverage.Add Additional EmployeesAdd Additional Employees*Do you have additional employees to add? If yes, this page will submit and refresh, allowing you to add another employee. Yes, add additional employees No, I am all finished Δ
