Care Navigation Form

Care Navigation Form

Please fill out the information below so that we can help you find a Provider.
Introduction:

At Solidarity, we believe our Members have the right to direct their own healthcare. You have the ability to see any healthcare provider of your choosing. Care Navigation services are intended to help you locate the best provider option for your specific situation. If you need help locating a provider, please fill out the information below and our Care Navigation Team will contact you about provider options.

Please note that every effort is made to ensure the accuracy of the information provided, but we cannot guarantee all information will be current. We appreciate feedback to help us provide the most accurate information possible to help serve our Membership.

If you would like to nominate any of your providers to try and expand our Preferred Provider relationships, please fill out a Provider Nomination Form.

If you have any questions, please contact our team at info@solidarityhealthshare.org or call us at (844) 313-4999 option 2.
Is this request related to an upcoming surgery, current cancer treatment or maternity services?*

YesNo
Please note: If this request is being submitted related to an upcoming surgery, current cancer treatment or maternity services, this request needs to go through our Care Coordination team. Please fill out the Inquiry Form here.
Membership ID Number*
Member Full Name*

First NameLast Name
Contact Email Address*

Confirmation Email
Contact Number*
Please enter a valid phone number.

Navigation Information Needed
How to search for Navigation Options

City/StateZip CodeBoth
City/State Search Area*

Street Address

Street Address Line 2

CityState

Zip Code
Zip Code Search Area*
Specialty*
If the specialty you are looking for isn't in these options above, please select "Other"
If "Other" was selected, please describe Specialty
Would you like to select another specialty for navigation options?*

YesNo
Specialty 2*
If the specialty you are looking for isn't in these options above, please select "Other"
If "Other" was selected, please describe Specialty
Would you like to select another specialty for navigation options?*

YesNo
Specialty 3*
If more than 3 specialties are needed for nomination, please fill out another form. If the specialty you are looking for isn't in these options above, please select "Other"
If "Other" was selected, please describe Specialty

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 the information below to help us get you scheduled for your imaging!
Is your upcoming service related to an MRI or Nuclear Imaging (PET Scan, Bone Scan, etc...)?*

YesNo
If yes, do you have an approved Pre-Notification on file?*

YesNo
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.
Please select the type of imaging service*
CPT Code (Preferred) or Description of Service*

Review Your Care Navigation Information
Please review the information you entered before submitting your form

Membership ID Number: {MembershipId}

Member Name: {MemberName}

Member Email: {MemberEmail}

Member Phone: {contactNumber}

Navigation Search Area: {CityState} {Zip}

Specialty: {Specialty1} {Specialty2} {Specialty3}
Other Specialty: {ifother1} {ifother2} {ifother3}
Should be Empty:

Care Navigation Form

Navigation Information Needed

Imaging

Low Dose Cancer Screening

Mammogram Screening

CT Screening

Breast MRI Screening

MR Contrast Exams

MRI Screening

CT/IVP Contrast Exam

Imaging

Review Your Care Navigation Information