Solidarity HealthShare Inquiry Form

Solidarity HealthShare

Care Coordination Inquiry Form
Description:

If you are a Solidarity Member who requires services related to Surgery, Maternity, Imaging, Cancer, or Pastoral Care our team is here to serve you! Please start by filling out the form below and giving as much detail as possible about your situation. Once the form is submitted you will receive an email from our team with more information. If this is related to an urgent need, such as a date of service in the next 24 hours, please call us at 844-313-4999.
Member Name*

First NameLast Name
Membership ID Number*
Member Email*
example@example.com
Select Service *
Date of Service or Date of Diagnosis *

MonthDayYear
Date of service is required information, ONLY in the case that services are not scheduled please type in 00-00-0000.
Last Menstrual Period (LMP)

MonthDayYear
Date
Estimated Due Date (EDD)*

MonthDayYear
Date
Type of Service (Please be as detailed as possible)*
Ex. Imaging, Colonoscopy, Knee Replacement...
Who is Requesting Payment?

FacilityProviderBothOther
Name of Facility
Facility Contact Information
Name of Provider
Provider Contact Information
Have you previously spoken with a Care Coordinator about this issue?*
Description of the situation or specific questions you have.

Imaging
Please note that a referral/order is needed to obtain your imaging. If you do not have a referral/order, please contact your physician.

We have partnered with Green Imaging, a full service national imaging company, which provides exceptional services at fair and just costs for Solidarity Members.

Please fill out this form to help us get you scheduled for your imaging!
If your upcoming service is an MRI or Nuclear Imaging, these imaging services require an approved Pre-Notification. It is advised to have your physician fill out a Pre-Notification form on your behalf. To obtain the Pre-Notification form, please click here.

Solidarity HealthShare