New Member Program Update Form

Thank you for submitting your application to become a Member of the Solidarity HealthShare community.

During your application process, Solidarity released a brand-new pricing structure for our Members. Because of this new pricing structure, you now have additional pricing and Annual Unshared Amount options to choose from for your Solidarity Membership that were not available to select on your application. These new options will go into effect for all Solidarity Members on November 1, 2021.

Please use this form to notify Solidarity HealthShare of which new Membership program you would like to select. We anticipate this process should take less than 10 minutes.

If you have any questions about the new options, please do not hesitate to contact our Onboarding Specialists on the Member Development team.

Email: memberdevelopment@solidarityhealthshare.org

Phone: (844) 313-4999, Option 1

Note: This form is only intended to communicate your new Membership program selection. You will not be able to change your Solidarity HealthShare application using this form. If you need to make updates to your application, please contact enrollment@solidarityhealthshare.org.

Applicant Information:

Primary Applicant Name: {primaryApplicantName}

Address: {applicantAddress}

Email: {primaryApplicantEmail}

Phone: {applicantPhone}

Your New Program Selection

You elected to begin your Solidarity Membership on {effectiveDateSelection} and have selected a {householdSizebeforeNov1} program where the oldest active Member is {ageOldestSinglebeforeNov1}{ageOldestCouplebeforeNov1}{ageOldestFamilybeforeNov1} years old as of November 1, 2021. 

Your new program selection is {programSingle0to24beforeNov1}{programCouple0to24beforeNov1}{programFamily0to24beforeNov1}{programSingle25to34beforeNov1}{programCouple25to34beforeNov1}{programFamily25to34beforeNov1}{programSingle35to44beforeNov1}{programCouple35to44beforeNov1}{programFamily35to44beforeNov1}{programSingle45to54beforeNov1}{programCouple45to54beforeNov1}{programFamily45to54beforeNov1}{programSingle55to64beforeNov1}{programCouple55to64beforeNov1}{programFamily55to64beforeNov1}{programSingle65andOverbeforeNov1}{programCouple65andOverbeforeNov1}{programFamily65andOverbeforeNov1}. Your new Monthly Contribution amount will appear on your November Share Notice posting in your Member Care Portal in October 2021.

Your Effective Date

• Once your Member Application is approved, the program level you requested (Premier, Plus, or Primary) is active until October 31, 2021. If you selected a Solidarity ONE program, your Effective Date will then change to November 1, 2021.

• If you selected the Legacy Premier program option, your Effective Date will remain the same as selected on your application.

Applicant Information:

Primary Applicant Name: {primaryApplicantName}

Address: {applicantAddress}

Email: {primaryApplicantEmail}

Phone: {applicantPhone}

Your New Program Selection

You have elected to begin your Solidarity Membership on {effectiveDateSelection}. You have also selected a {householdSizeafterNov1} program where the oldest active Member is {ageOldestSingleafterNov1}{ageOldestCoupleafterNov1}{ageOldestFamilyafterNov1} years old as of November 1, 2021. 

Your new program selection is {programSingle0to24afterNov1}{programCouple0to24afterNov1}{programFamily0to24afterNov1}{programSingle25to34afterNov1}{programCouple25to34afterNov1}{programFamily25to34afterNov1}{programSingle35to44afterNov1}{programCouple35to44afterNov1}{programFamily35to44afterNov1}{programSingle45to54afterNov1}{programCouple45to54afterNov1}{programFamily45to54afterNov1}{programSingle55to64afterNov1}{programCouple55to64afterNov1}{programFamily55to64afterNov1}{programSingle65andOverafterNov1}{programCouple65andOverafterNov1}{programFamily65andOverafterNov1}.

1. I have recorded my application information accurately to the best of my knowledge.
2. I reviewed my program change request and accept the change.
3. I understand that if I elected an Effective Date of September 1, 2021 or October 1, 2021, and also selected a Solidarity ONE program, my Annual Unshared Amount will reset effective November 1, 2021.
4. I understand and accept my updated Monthly Contribution Amount.