Primary Member or Roll-Off Membership Change

Instructions

Please use this form to notify Solidarity HealthShare that you would like to change the Primary Member on your Membership or roll off a current Member of your Membership to a new Solidarity HealthShare Membership. 

Important: A Primary Member change and Member roll-off change will require a new Solidarity Membership with a Membership new effective date and new Membership ID. For more information on this specific type of request and all applicable changes, visit our Knowledge Center.

As a reminder, all Membership change requests require that notification is received by the first day of the month prior to the month in which the Member intends for the changes to take effect. Membership changes cannot be applied to a retroactive date. 

Before starting this form, be sure to have the following available:

• Your Member ID card
• Your current Membership information
• The name of the Solidarity ONE program you would like to select for your new Membership.
• Review the current pricing of all Soldiarity HealthShare programs by using the pricing calculator.

 

Note: This form will only accept changes to current, active Members on your Membership. If a new Member needs to be added to your new Membership, please use the "Add a Member" form to add a new Member once this change is complete. Per the Sharing Guidelines, all new Members will be subject to a Medical History Review and a 60-day waiting period.

Because you selected Telehealth or the Dental and Vision discount program as an add-on to your new program, please review the following requried agreements related to these services.

Terms & Conditions

Terms and Conditions: The Terms and Conditions you have accepted or will accept upon registering at www.dialcare.com, are part of this membership agreement (Agreement) between you and DialCare, LLC (“DialCare”). DialCare provides administrative services to DialCare clinicians and does not provide professional medical services.  The Terms and Conditions define the obligations of DialCare, its authorized agents and yourself, and they establish the basic rules of safe and fair use of DialCare’s public website, member website, and services (Services). DialCare and its authorized agents reserve the right to immediately and without advance notice terminate the Services and deny access to individuals who do not abide by the Terms and Conditions.

Purchase and Renewal Conditions: By joining a plan, for yourself or on behalf of a minor child for whom you are a parent or legal guardian, you confirm that you are at least 18 years old and you authorize Solidarity HealthShare to charge your credit card or checking account for the plan you have selected. By joining, you indicate you have read and agree to the terms and conditions of the plan.

This charge will automatically renew at the end of your membership term, and your credit card or checking account will be automatically charged for the appropriate amount, until you notify Solidarity HealthShare that you wish to cancel the plan.

Termination Conditions: Solidarity HealthShare and DialCare reserve the right to terminate plan members from its plan for any reason, including non-payment. If Solidarity HealthShare terminates the plan or your membership for a reason other than non-payment, you will receive a pro-rata refund of your membership fees.

Cancellation Conditions:  You have the right to cancel within the first 30 days after effective date or receipt of membership materials (whichever is later) and receive a full refund, less the processing fee, if applicable. If for any reason you wish to cancel, submit a cancellation request with your name and member ID by mail to Solidarity HealthShare, 4500 S Lakeshore Drive, Ste. 130, Tempe, AZ 85282, or phone. Solidarity HealthShare will stop collecting membership fees in a reasonable amount of time, but no later than 30 days after receiving a cancellation request. When you cancel, you will continue to have access to the plan for the remainder of the period for which you have paid; your membership will terminate at the end of that period. The preceding sentence does not apply to quarterly, semi-annual or annual memberships in FL and OK, where you will receive a pro-rata refund whenever you cancel.

Description of Services: Please see the enclosed materials for a specific description of the programs included in your plan.

Limitations, Exclusions and Exceptions: This is a discount plan offered by Careington. Careington is not a licensed insurer, health maintenance organization or other underwriter of health care services. This plan is not insurance. No portion of any provider’s fees will be reimbursed or otherwise paid by Careington. Careington is not licensed to provide and does not provide health care services or items to individuals. You will receive discounts for services at certain health care providers who have contracted with the plan. You are obligated to pay for all health care services at the time of service. Savings are based upon the provider’s normal fees. Actual savings will vary depending upon location and specific services or products purchased. Please verify such services with each individual provider. The plan’s discounts may not be used in conjunction with any other discount plan or program. All listed or quoted prices are current prices by participating providers and subject to change without notice. Any procedures performed by a non-participating provider are not discounted. From time to time, certain providers may offer products or services to the general public at prices lower than the discounted prices available through this plan. In such event, members will be charged the lowest price. Discounts on professional services are not available when prohibited by law. This plan does not discount all procedures. Providers are subject to change without notice and services may vary in some states. It is your responsibility to verify that the provider participates in the plan. At any time Careington may substitute a provider network at its sole discretion. Careington cannot guarantee the continued participation of any provider. If the provider leaves the plan, you will need to select another provider. Providers contracted by Careington are solely responsible for the professional advice and treatment rendered to members and Careington disclaims any liability with respect to such matters

Complaint Procedure: If you would like to file a complaint, you must submit your complaint in writing to:  DialCare, P.O. Box 2568, Frisco, TX 75034. You have the right to request an appeal if you are dissatisfied with the complaint resolution. After completing the complaint resolution process, if you remain dissatisfied you may contact your state insurance department. Contact information for your state insurance department is available upon request. 

New Primary Member Information:

New Primary Member Name: {nameOfNewPrimaryMember}

Address:  {newPrimaryAddress}

Email: {newPrimaryEmailAddress}

Phone:  {newPrimaryPhoneNumber}

Active Sharing Member or Guardian to Dependents Only: {newPrimaryGuardian}

 

New Membership Information

Requested Effective Date: {requestedEffectiveDate}

Solidarity Program Selection: {solidarityProgram}

New Program AUA: {OneAUA}{SavvyAUA}{ShieldAUA}

New Program Add-On Selection (if applicable):

{SavvyAddOnOptions}{SheldAddOnOptions}

{SavvyRXOption}

 

Dependents Moving to New Membership: {dependentsMoving}

 {dependentMovingName}

 

Current Membership

Current Primary Member Name: {currentPrimaryName}

Current Primary Member Active or Cancelling: {currentPrimaryActiveorCancel}

Other Dependents Cancelling: {dependentCancelling}

{dependentCancellingName}

Requested Cancellation Date for Current Membership:  {currentMembershipCancellationDate}

PROGRAM, NOT INSURANCE. I acknowledge that I am enrolling in Solidarity HealthShare, a healthcare sharing ministry of Melita Christian Fellowship Hospital Aid Plan, that is voluntary and cooperative and not insurance. I have read and understand any disclaimer to this effect and understand that there are no representations, promises or guarantees that my medical expenses will be paid. I also understand that any funds that I may receive for medical expenses do not come from an insurance plan, but are voluntary donations by the members.

MEMBERSHIP CHANGE REQUEST. I acknowledge that by requesting Membership changes to my active Solidarity HealthShare Membership that I will i) be converted to a new Membership, ii) be issued a new Member ID number, iii) change my Effective Date, iv) forfeit the Legacy Premier program and be converted to a Solidarity ONE program (if applicable) v) have my Annual Unshared Amount reset upon my new Effective Date, vi) have the 60-day waiting period waived, vii) have the $!35 enrollment fee waived, viii) continue any current pre-existing condition(s) timelines from my current Membership to my new Membership.

CHANGES TO SHARING GUIDELINES. I acknowledge that amendments to the Guidelines will take effect as soon as is administratively practical or as designated by the Board of Directors. Dates of Service of medical expenses submitted for sharing will be subject to the edition of the Guidelines in effect when recorded as received by Solidarity HealthShare and supersedes all other editions of the Guidelines and any other communications, written or verbal.

CALCULATIONS OF SUGGESTED MONTHLY CONTRIBUTION AMOUNT. I acknowledge that the suggested Monthly Contribution Amount is calculated on the total number of healthcare sharing ministry members, the amount of medical expenses submitted for sharing, and the administrative cost of operating the healthcare sharing ministry program. I further acknowledge that the suggested Monthly Contribution Amount is calculated on a periodic basis as needed and is subject to change. I understand that the contribution of the suggested Monthly Share Amount is voluntary and that I am not obligated to send any money.

ACCOUNT FEE. Solidarity HealthShare account service fee is for the costs of processing the Monthly Contribution and can be discounted if the member uses Automated Clearing House (ACH) for the Monthly Contribution.

OPTIONAL COMMUNICATION BETWEEN MEMBERS. I acknowledge that Solidarity HealthShare’s cost sharing technology also enables Members to send one another notes of encouragement or prayer and, and, upon activation of their Sharing Account, that each Member can choose how to be identified in this system or to remain anonymous.

APPLICATION ACCEPTANCE. I acknowledge that Solidarity HealthShare, pursuant to the Sharing Guidelines, has the discretion to accept, reject, or modify my membership. I will not assume that my application has been accepted until I have received a written confirmation from Solidarity HealthShare.

ACCEPTANCE OF GUIDELINES. I have read and understand the Sharing Guidelines and accept them as the guiding document for all interactions among members and for determining the eligibility of medical expenses that I may submit for sharing. If a difference of opinion should arise as to the use, application or interpretation of those Sharing Guidelines, I will follow the appeal process outlined in the Sharing Guidelines for the resolution of any or all disputes. I acknowledge that I will treat all Solidarity HealthShare employees and representatives with mutual kindness and respect as taught by the Gospel of John 13:34 “I give you a new commandment: love one another. As I have loved you, so you also should love one another.”

PAYMENT OF MEDICAL NEEDS. I acknowledge that any medical need shared will be used for the sole purpose for which it was shared.

STATEMENT OF BELIEFS.  Solidarity HealthShare is made up of like-minded individuals who voluntarily share one another’s medical expenses. Our core ethical beliefs mobilize our actions, and we are related to one another in community because of them. We ask that each member subscribe to the following Shared Beliefs:

1. We believe that our personal rights and liberties originate from and are bestowed on me by God and are not concession granted to us by governments or men.
2. We believe every person has a right to exercise his or her religion without interference or coercion. While we do not hold that every claim made in the name of religion has equal merit or equal basis in truth, we do respect each person’s freedom of both religious worship and practice.
3. We believe it is our moral and ethical obligation to be our brother’s or sister’s keeper, in recognition of the principle of solidarity, according to our God-given resources and opportunity.
4. We believe in the virtue of temperance, which enables us to maintain a healthy lifestyle and avoid foods, behaviors, or habits that could produce sickness or disease.
5. We believe it is our fundamental right of conscience to direct our own healthcare, in consultation with physicians, family or other valued advisors, free from government dictates, restraints and oversight, including federal or state contraception and abortion mandates and all unethical practices or mandates.

By signing below, I acknowledge that I have read the entire agreement in full and agree to comply with the above policies and Guidelines of Solidarity Healthshare. I acknowledge that I understand all terms, language, and concepts herein.