Amexem-Moor-Empire: Department For The Health And Phytotherapy: Imperial-Health And Dental-Agency: Non-Surgical: Universal-Healthcare-Plan: Annual-Subscription-Application-Form
Amexem-Moor-Empire: Department For The Health And Phytotherapy
Amexem-Moor-Empire: Fahs-Al-Suradiq
Agade-Medina, Ta-Seti: District
North-Amexem, Amexem-Moor-Empire
Imperial-Health And Dental-Maintenance-Agency
Non-Surgical: Universal-Healthcare-Plan: Application
Are-you-an: Amexem-Moor-Empire: National? Yes___ No___
Are-you-an: Amexem-Moor-Empire: National in the compliance/good-standing on the record before the Amexem-Moor-Empire: Department For The Admissions? Yes___ No___ (If-yes: Attach the confirmation-document from the Amexem-Moor-Empire: Department For The Admissions: Compliance-Staff. Monthly-Contribution-Receipts and Monthly-Volunteer: Time-Compliance-Records: are-required-to get the confirmation-document: If-no: Get-in-compliance and apply for the Non-Surgical: Universal-Healthcare-Plan: then).
If-you-are-not-an: Amexem-Moor-Empire: National, do-you-have-a-healthcare-waiver from the Amexem-Moor-Empire: Department For The Foreign-Affairs for the providing of the consent for the participating within the Amexem-Moor-Empire: Department For The Health And Phytotherapy: Imperial-Health And Dental-Agency: Non-Surgical: Universal-Healthcare-Plan (You-are-not-eligible: to-get-permission for the entry into the Dominions Of The Realm of the Amexem-Moor-Empire: Constitutional-Monarchy from the Amexem-Moor-Empire: Department For The Interior: Department For The Admissions without the healthcare-waiver. Unauthorized-entry = automatic-arrest by the Amexem-Moor-Empire: Imperial-Customs-Force for the Class: A, B, or C: Border-Breach)? Yes___ No____ (If-yes: Attach the Amexem-Moor-Empire: Department For The Foreign-Affairs: Healthcare-Waiver: If-no: Contact the nearest: Amexem-Moor-Empire: Local-Government: Command-Authority, request-an-appointment for the healthcare-waiver-interview plus the appointment for the interview for the Amexem-Moor-Empire: Department For The Admissions: Point-Of-Entry: Visa upon the receiving of the healthcare-waiver).
Step 1: Tell us about yourself regarding habits, family-dynamics, lifestyle activities for you and those comprising your household, pets, pet types, amount-of-pets, and the condition of the domicile you and your household dwell or abide in as your regular abode (Include the water quality, insect/pest population level, pest-control-method):
We require one adult in the household to be the primary-contact for your application:
Full-Appellation:
Domicile-Location:
Mailing-Location:
Contact-Number:
Trade-Contact-Number:
Emergency-Contact
Email:
Step 2: Tell us about yourself and everyone comprising your household:
Full-Appellations for everyone comprising your household:
Pre-existing-conditions for you:
Pre-existing-conditions for everyone comprising your household:
Are you an organ transplant recipient? Yes____ No____
Identify anyone comprising your household that is an organ transplant recipient:
Date of the transplant:
Location of the transplant:
Facility/Hospital where the transplant-happened:
Doctor/Surgeon that performed the procedure:
Alcohol abuse diagnosis: Yes____ No____ Treatment: Yes____ No____
Drug/Controlled-Substance-Abuse: Yes___ No___ Treatment: Yes___ No___
Are you under the care/treatment of a Psychologist? Yes___ No___
Identify anyone comprising your household under the care/treatment of a Psychologist:
A. Are you under the care/treatment of a Psychiatrist? Yes____ No____
B. Identify anyone comprising your household that is under the care/treatment of a Psychiatrist:
Do you have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily chores, etc.), a special health care need? Yes____ No____
Does anyone comprising your household have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily chores, etc.), a special health care need? Yes____ No____
Identify everyone comprising Does anyone comprising your household have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily chores, etc.), a special health care need? Yes____ No____
The cost for the Amexem-Moor-Empire: Plan For The Universal-Health-Care for the Amexem-Moor-Empire: National in the good-standing = three-ounces of the silver in the bar/coin-form (36: ounces of the silver for the Earth-Year), per-month for an individual and six-ounces of the silver in the bar/coin-form (72: ounces of the silver for the Earth-Year), per-month for a household-of-6-or-less. For-every: additional-nuclear-family-member unto the total = six, add-2: ounces of the silver in the bar/coin-form. More than six, add: 3: ounces of the silver, each, family-member beyond the six. The-fee/fees of the stating-herein can be paid monthly, quarterly or annually as specified upon the acquiring of the Amexem-Moor-Empire: Plan For The Universal-Health-Care: Service and is not amendable until the next-service-year. Currently the Amexem-Moor-Empire: Plan For The Universal-Health-Care, is available through the video-conference-call with the including of the minor-emergencies.
The cost for the Amexem-Moor-Empire: Plan For The Universal-Health-Care for the non: Amexem-Moor-Empire: National with the Amexem-Moor-Empire: Department For The Foreign-Affairs: Healthcare-Waiver = four-ounces of the silver in the bar/coin-form (48: ounces of the silver for the Earth-Year), per-month for an individual and seven-ounces of the silver in the bar/coin-form (84: ounces of the silver for the Earth-Year), per-month for a household-of-6-or-less. For-every: additional-nuclear-family-member unto the total = six, add-3: ounces of the silver in the bar/coin-form. More than six, add: 4: ounces of the silver, each, family-member beyond the six. The-fee/fees of the stating-herein can be paid monthly, quarterly or annually as specified upon the acquiring of the Amexem-Moor-Empire: Plan For The Universal-Health-Care: Service and is not amendable until the next-service-year. Currently the Amexem-Moor-Empire: Plan For The Universal-Health-Care, is available through the video-conference-call with the including of the minor-emergencies.
Applicant specifies the request-for-service covers the Applicant and household participating in the Non-Surgical: Universal-Healthcare-Plan (Write-your-full-appellation as the Applicant and add the full-appellation-of-every-member-of: your-household: being-included in the annual-subscription for the service: Separate all of the appellations: by-comma)
Applicant-chooses the payment-method = Monthly____ Quarterly____ Annually_____
Applicant-acknowledges the Amexem-Moor-Empire: Imperial-Court as the Court Of The Original-Jurisdiction for the any-dispute-resolution regarding the contract-for-service relevant unto the Amexem-Moor-Empire: Department For The Health And Phytotherapy: Imperial-Health And Dental-Maintenance-Agency: Non-Surgical: Universal-Healthcare-Plan.
Applicant-specifies of the all of the foregoing-information-provided by the Applicant = True, correct, and complete under the penalty-of-perjury amenable before the Amexem-Moor-Empire: Imperial-Court by the pursuing of the Amexem-Moor-Empire: Constitution: Article: 3, ex-continenti by the Amexem-Moor-Empire: Department For The Law And Justice: District: Imperial-Prosecutor.
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Service-Applicant
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Witness (Deuteronomy: 19:15)
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Witness (Deuteronomy: 19:15)
Amexem-Moor-Empire: Sovereign-Copyright-Number: SC03282022CE008
Non-Surgical-Application: Form
(Print, fill out and send with payment)
