Healthcare Membership Form

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.
Date*
MonthDayYearHourMinutesAM/PM Option
MAR Requested By*
First NameLast Name
MAR Requestor's Email Address*
Member's Name*
First NameLast Name
ID Number*
9 digit ID #
Member's Address*
City*
State*
Zip*
Hospital Name (from AS400)*
E-mail
Reason for Request
Scroll to appropriate section below to enter required details.
Change Source Code and/or Expiration Date
Current Source Code
Requested Source Code
Current Expiration Date
Requested Expiration Date
Reason
Reverse Renewal
Prior Membership Type (N, R, E or T), Source Code, Renewal Date and Expiration Date will be reinstated.
Entry Date
Reason
Transfer Membership
From Hospital Chapter # / Name
To Hospital Chapter # / Name
Reason
Delete Duplicate Profile
Unless otherwise requested, the Original ID will be kept to maintain original member date and membership history.
Original Member ID #
Duplicate Member ID #
Reason
Refund Request
Refund checks are generated once a month and will be mailed to the member at the address above.
Amount Requested
Reason
Terminate Membership
Membership type will be changed to T. History will be saved, but member will no longer receive mailings or renewal notices.
Reason
Other
Describe
E-mail
E-mail
E-mail
Should be Empty: