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  • Company Information

  • Name of company, DBA or sole proprietorship.

  • Employee Information

  • Select the age group that you are in.
  • Enter Tax ID or SSN for Spouse.
  • Important: Fields do not validate. Please enter date of birth using mm/dd/yyyy format. Please enter tax ID using xxx-xx-xxxx format. Use "+" button on right side to add additional dependents.
    First NameLast NameDate of BirthTax IDM/F 
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  • Enrollment Plan Selection

    Select the plans that you wish to offer or enroll in. Additional setup may be required for some plan types.

  • You may select one preventive health plan or membership plan option. See plan options.
  • You may select one preventive health plan or membership plan option. See plan options.
  • You may select one preventive health plan or membership plan option. See plan options.
  • You may select one preventive health plan or membership plan option. See plan options.
  • You may select one preventive health plan or membership plan option. See plan options.
  • You may select one preventive health plan or membership plan option. See plan options.
  • You may select one preventive health plan or membership plan option. See plan options.
  • You may select one preventive health plan or membership plan option. See plan options.
  • The amount entered will be added to your Preventive HSA plan and deposited into your Health Savings Account (HSA) account. The account will be with Optum Bank. You will receive a debit card that will allow access to these funds for qualified medical expenses.
    Please enter a number from 1 to 583.

  • You may select one catastrophic plan. You have the choice of a $1,000, $2,500 or $5,000 Initial Unshareable Amount (IUA). See plan options. Ages 18-29
  • You may select one catastrophic plan. You have the choice of a $1,000, $2,500 or $5,000 Initial Unshareable Amount (IUA). See plan options. Ages 30-49
  • You may select one catastrophic plan. You have the choice of a $1,000, $2,500 or $5,000 Initial Unshareable Amount (IUA). See plan options. Ages 50-64
  • You may select one catastrophic plan. You have the choice of a $1,000, $2,500 or $5,000 Initial Unshareable Amount (IUA). See plan options. Ages 18-29
  • You may select one catastrophic plan. You have the choice of a $1,000, $2,500 or $5,000 Initial Unshareable Amount (IUA). See plan options. Ages 30-49
  • You may select one catastrophic plan. You have the choice of a $1,000, $2,500 or $5,000 Initial Unshareable Amount (IUA). See plan options. Ages 50-64
  • You may select one catastrophic plan. You have the choice of a $1,000, $2,500 or $5,000 Initial Unshareable Amount (IUA). See plan options. Ages 18-29
  • You may select one catastrophic plan. You have the choice of a $1,000, $2,500 or $5,000 Initial Unshareable Amount (IUA). See plan options. Ages 30-49
  • You may select one catastrophic plan. You have the choice of a $1,000, $2,500 or $5,000 Initial Unshareable Amount (IUA). See plan options. Ages 50-64
  • You may select one catastrophic plan. You have the choice of a $1,000, $2,500 or $5,000 Initial Unshareable Amount (IUA). See plan options. Ages 18-29
  • You may select one catastrophic plan. You have the choice of a $1,000, $2,500 or $5,000 Initial Unshareable Amount (IUA). See plan options. Ages 30-49
  • You may select one catastrophic plan. You have the choice of a $1,000, $2,500 or $5,000 Initial Unshareable Amount (IUA). See plan options. Ages 50-64
  • Additional $50 monthly fee is added for tobacco users. You should select yes if you have used tobacco products in the last 12 months.
  • 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 NameConditionLast Treatment Date 
  • By joining a HealthShare, you agree to live by the stands of good health. These standards include avoiding illegal drugs and excessive alcohol use. It is encouraged to try and maintain a healthy life style including exercise and proper nutrition.

  • Zion Health's medical cost sharing membership is included as part of your Access Care membership at a $1,000 Initial Unsharable Amount (IUA).

  • Additional $50 monthly fee is added for tobacco users. You should select yes if you have used tobacco products in the last 12 months.
  • 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 NameConditionLast Treatment Date 
  • By joining a HealthShare, you agree to live by the stands of good health. These standards include avoiding illegal drugs and excessive alcohol use. It is encouraged to try and maintain a healthy life style including exercise and proper nutrition.

  • Select your accident plan election. See dental plan to learn more.
  • Select your dental plan election. See dental plan to learn more.
  • Select your dental plan election. See dental plan to learn more.
  • Select your dental plan election. See dental plan to learn more.

  • Select your vision plan election. See vision plan to learn more.
  • Select your vision plan election. See vision plan to learn more.
  • Select your vision plan election. See vision plan to learn more.
  • Select your vision plan election. See vision plan to learn more.

  • Effective 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.
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Claim Information

Payer ID:
65241

Claim Address:
Planstin Administration
P.O. Box 21747
Eagan, MN 55121

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