Medical Expense Need Agreement

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I acknowledge that it would be a violation of the trust placed in me by my fellow members within the Solidarity HealthShare sharing community if I used the funds received for my medical expense need for any other reason than to pay my medical bills. Therefore, I do hereby pledge, agree and commit, without reservation or intent to deceive, to only use the amounts donated to my online “Member Care Portal” to reimburse my medical providers. I do also direct Solidarity HealthShare to cause those funds to be disbursed in the amounts, and according to the schedule set by Solidarity HealthShare, by means of payment, electronic or otherwise, to the medical service provider’s last known address.

Primary Member Name*

First NameLast Name

Primary Member Email Address*

example@example.com

Member ID Number*

Your Member ID Number will be 9 digits long and can be found on your Member ID card

Primary Member Signature*

Today's Date*

Spouse Name (if applicable)

First NameLast Name

Spouse Signature (if applicable)