Healthcare Membership Form

Healthcare Membership Form

Make it easier and convenient for your customers to apply healthcare membership through this form. Use this to collect and update customers personal information as well as information about their healthcare coverage. Create a HIPAA Compliant Healthcare Membership Form today. Form Preview
  • Our Healthy Circle

    Member Action Request (MAR)

    Please complete a separate form for each member.

  • Advisors can change name, address, payment info & status to deceased.

    Complete this form to request other changes to a member's profile in AS400.
  •  -  -
    Pick a Date
  • Change Source Code and/or Expiration Date

  • Reverse Renewal

    Prior Membership Type (N, R, E or T), Source Code, Renewal Date and Expiration Date will be reinstated.
  • Transfer Membership

  • Delete Duplicate Profile

    Unless otherwise requested, the Original ID will be kept to maintain original member date and membership history.
  • Refund Request

    Refund checks are generated once a month and will be mailed to the member at the address above.
  • Terminate Membership

    Membership type will be changed to T. History will be saved, but member will no longer receive mailings or renewal notices.
  • Other

  • Should be Empty: