Member Exclusion Request

Member Exclusion Request Form

Please use this form to request the removal of a spouse or dependent Member from your Membership.
Instructions:

Use this form to request that a Spouse or Dependent be removed from your Membership as of the end of a future sharing month. According to our Sharing Guidelines, Membership changes must be requested by the first (1st) day of the month prior to the month in which the change will take effect.

If you need to exclude the Primary Member on your Membership, please fill out the Primary Member or Roll-Off Membership Change Form instead.

Information you will need to submit your exclusion request:

- Membership ID Number

- Primary Member's Full Name

- Primary Member's Email Address

- Name of Member to be Excluded

- Date of Member Exclusion

Please Note: If the Member you are excluding wishes to become active again in the future, you will need to apply for them to join again using our Add a Member form. That will not reactivate their current Membership, but will add them again as a new Member instead.

Primary Member Full Name*

First NameLast Name
Membership ID Number*
Your Member ID Number will be 9 digits long
Primary Member Email Address*

Confirmation Email
Are you excluding a Spouse or Dependent?*
Name of Member to be Excluded*

First NameLast Name
Reason for Member Exclusion
Spouse Email
example@example.com
Since the spouse on this Membership will be removed, Solidarity HealthShare requires written verification and approval directly from the spouse that is to be removed from the current Membership. This request will not proceed until Solidarity HealthShare receives verification. However, Solidarity HealthShare may remove the spouse from the Membership due to non-response after a reasonable number of attempts or upon receipt of an official court document, such as a divorce decree. A message will be sent to the spouse upon submission of this form.

I understand that a spouse must submit a written verification that he or she approves the request to be removed from the current Membership.
Date of Member Exclusion*

MonthDayYear
Must be the last day of a future month

Review Member Exclusion Request

Please review the information you entered to make sure that it is correct before submitting your Member Exclusion Request.
Membership ID Number: {MemIDNumber}

Primary Member Full Name: {PrimaryMemName}

Primary Member Email Address: {PrimaryMemEmail}

Name of Member to be Excluded: {ExcludedMem}

Date of Member Exclusion: {ExclusionDate}

Exclusion Reason: {ExclusionReason}
By signing below, I acknowledge that I have read and understood the Sharing Guidelines regarding Member exclusion.
Primary Member's Signature*

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

Member Exclusion Request Form