I have read and understand the membership guidelines and accept them as the governing document for determining eligibility of my, or anyone else’s medical needs submitted to Altrua HealthShare.

I further agree to hold GAP Healthcare and its trustees, officers, employees, representatives and service providers harmless, and to limit any dispute I may have over the eligibility of my, or anyone else’s medical needs to the appeal procedure described in the guidelines.

So as not to take advantage of my fellow members, I have answered all questions in this application in good faith, truthfully, completely and accurately.

In recognition of the voluntary nature of the membership, I hereby promise that in the event of a disagreement over the payment of my or anyone else’s medical needs, my dependents and I will bring no legal claim, demand or suit of any kind for unpaid medical expenses, but will follow the appeal and mandatory mediation procedure described in the guidelines. I and my dependents also accept and appoint Altrua HealthShare as the final authority on the interpretation of the guidelines and, agree to indemnify and hold harmless Altrua HealthShare and its trustees, officers, employees, representatives and service providers from any damages or expenses, including legal fees, arising from any breach of these promises, from any failure to follow the guidelines, or from any failure to provide accurate, complete and honest information to Altrua HealthShare.