Voluntary Membership Withdrawal

Voluntary Membership Withdrawal

Use this form to confirm the voluntary withdrawal of your Solidarity HealthShare Membership.
According to our Sharing Guidelines, if you wish to withdraw your membership you must submit your confirmation by the 1st day of the month prior to the month in which you intend to withdraw membership.

If you withdraw your Membership more than 30 days after your Membership effective date, Membership fees will not be refunded.

Information you will need to submit your confirmation:

- Membership ID Number

- Primary Member's Full Name

- Primary Member's Email Address

- Date of Membership Withdrawal

Please Note: If you withdraw your Membership participation and wish to become active again in the future, you will need to reapply as a new applicant and will not receive preferential treatment as your application is considered for acceptance. Reactivating your membership would give you a new effective date and would not retroactively move your previous effective date forward.

Membership ID Number*
Your Member ID Number will be 9 digits long
Primary Member Full Name*

First NameLast Name
Primary Member Email Address*

Confirmation EmailPlease enter your email and verify it. Emails must match.
Date of Membership Withdrawal*

MonthDayYear
Must be the last day of a future month.
Reason for Membership Withdrawal*

MedicareEmployer InsuranceOther InsuranceOther Healthcare Sharing MinistryFinancial DifficultiesDissatisfaction with ServicePricing ChangeOther
What aspect of the service were you dissatisfied with?

Review Membership Withdrawal

Please review the information you entered to make sure that it is correct before submitting your confirmation.
Membership ID Number: {MembershipID}

Primary Member Full Name: {PrimaryMemberName}

Primary Member Email Address: {PrimaryMemberEmail}

Date of Membership Withdrawal: {RequestedWithdrawalDate}
By signing below, I acknowledge that I have read and understood the Sharing Guidelines regarding voluntary withdrawal of membership.
Primary Member's Signature*

Clear
Please verify that you are human*
Should be Empty:

Review Membership Withdrawal