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PHONE HOTLINE: (855) 378-6777
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PHONE HOTLINE: (855) 378-6777
ENROLL NOW
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MEMBER FORMS

New: Wellness Visit Concierge Service Now Available

We’re making it even easier to use your Impact membership.
Our new Wellness Concierge service helps coordinate billing with your provider before your annual wellness visit, so everything is set up in advance.

It’s free, optional, and especially helpful for first-time visits.

Just submit the form at least 5 business days before your appointment. 

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BMI Verification

Measurements for height, and weight taken within the last 30 days are acceptable.
Extra Impact Application

Special assistance for Impact members in need.
Medical expense form - out of country

Submit medical expenses for processing that were incurred outside the United States.

pre-ELIGIBILITY

Providers, please request a pre-eligibility review by either calling (855) 378-6777 or completing the online form.

Get Started Online

Pre-eligibility reviews ensure that specific treatments are eligible for sharing before you receive them. Medical records are required for review.

Pre-eligibility submission is only for the following:

  1. Cancer Treatment
  2. Elective Cardiac Procedures
  3. Non-emergency inpatient/outpatient surgery
  4. Organ/Tissue Transplant Services
  5. Maternity
  6. Imaging: MRIs and Nuclear Imaging (excluding CT Scans and xrays)
**Please be advised that pre-eligibility is required only for non-emergent procedures/medical expenses. If member requires emergent services, please proceed without submitting a pre-eligibility request and eligibility will be determined post-procedure
Provider Outreach Request
  • Available only after an appointment is scheduled.
  • This form is for Provider Visits only.
  • Not applicable for Senior Program

Provider Outreach is for contacting your provider if they are unsure about accepting Impact Health Sharing.
PRA Change Request

Requests may be made annually within 30 days of membership date.
Request member Card

Submit a request for a new member card.
Wellness Rewards

(Formerly the Health & Wholeness Credit) Submit eligible receipts to reduce your annual household PRA.

  • DPC Membership (Direct Primary Care)
  • Gym Membership
  • Fitness Classes/Subscriptions (e.g., yoga, fitness apps like Peloton)
  • Massage Therapy
  • Acupuncture
  • Naturopathic Services
  • Supplements or Naturopathic Medications
Wellness Visit Concierge

Make your annual wellness visit even easier.
Use this optional service to have Impact coordinate billing directly with your provider, so everything is in place before your appointment.

  • Shared at 100%
  • Great for first-time visits
  • Submit the form at least 5 business days in advance
Provider Outreach Request
  • Available only after an appointment is scheduled.
  • This form is for Provider Visits only.
  • Not applicable for Senior Program
SR BLOG IMAGES (5)
Pre-Eligibility vs. Provider Outreach

Which one do I need?
Pre-eligibility ensures that specific treatments are eligible for sharing before you receive them. Medical records are required for review.
Provider Outreach is for contacting your provider if they are unsure about accepting Impact Health Sharing.

PRA Change Request

Requests may be made annually within 30 days of membership date.

blogImages - Impact (1200 x 630 px) (900 x 900 px) (950 x 700 px) (7)-1
Request member Card

Submit a request for a new member card. 

Video2

Member Video Tips

Going To The Doctor

Member Forms

Click to access or download each.

Add-On Family Form
Add-on a new family member.
BMI Verification
Measurements for height, and weight taken within the last 30 days are acceptable.
Extra Impact Application
Special assistance for Impact members in need.
Health & Wholeness Credit expense form
Submit expenses for the Health & Wholeness Credit for processing.
  • DPC (Direct Primary Care) memberships
  • Naturopathic Medications/Supplements
  • Acupuncture
  • Services rendered by Naturopathic Providers
  • Gym Memberships
Medical expense form - out of country
Submit medical expenses for processing that were incurred outside the United States.
pre-ELIGIBILITY
Providers, please request a pre-eligibility review by either calling (855) 378-6777 or completing the online form.
Get Started Online
Pre-eligibility submission is only for the following:
  1. Cancer Treatment
  2. Elective Cardiac Procedures
  3. Non-emergency inpatient/outpatient surgery
  4. Organ/Tissue Transplant Services
  5. Maternity
  6. Imaging: MRIs and Nuclear Imaging (excluding CT Scans and xrays)
**Please be advised that pre-eligibility is required only for non-emergent procedures/medical expenses. If member requires emergent services, please proceed without submitting a pre-eligibility request and eligibility will be determined post-procedure
Medical expense form
Submit medical expenses for processing.
Provider Outreach Request
  • Available only after an appointment is scheduled.
  • This form is for Provider Visits only.
  • Not applicable for Senior Program
Pre-Eligibility vs. Provider Outreach
Which one do I need?
Pre-eligibility ensures that specific treatments are eligible for sharing before you receive them. Medical records are required for review.
Provider Outreach is for contacting your provider if they are unsure about accepting Impact Health Sharing.
PRA Change Request
Requests may be made annually within 30 days of membership date.
Request member Card
Submit a request for a new member card. 

Member Forms

Click to access or download each.

Add-On Family Form Add-on a new family member. Get Started BMI Verification

Measurements for height, and weight taken within the last 30 days are acceptable.

 Get Started Extra Impact Application Special assistance for Impact members in need. Get Started Medical expense form Submit medical expenses for processing. Get Started Medical expense form - out of country Submit medical expenses for processing that were incurred outside the United States. Get Started PRA Change Request Requests may be made annually within 30 days of membership date. Get Started Provider Outreach Request
  • Available only after an appointment is scheduled.
  • This form is for Provider Visits only.
  • Not applicable for Senior Program
 Get Started Request member Card Submit a request for a new member card.  Get Started Health & Wholeness Credit expense form

Submit expenses for the Health & Wholeness Credit for processing.

  • DPC (Direct Primary Care) memberships
  • Naturopathic Medications/Supplements
  • Acupuncture
  • Services rendered by Naturopathic Providers
  • Gym Memberships
 Get Started
pre-ELIGIBILITY

Providers, please request a pre-eligibility review by either calling (855) 378-6777 or completing the online form.

Get Started Online ->

Pre-eligibility submission is only for the following:

  1. Cancer Treatment
  2. Elective Cardiac Procedures
  3. Non-emergency inpatient/outpatient surgery
  4. Organ/Tissue Transplant Services
  5. Maternity
  6. Imaging: MRIs and Nuclear Imaging (excluding CT Scans and xrays)

**Please be advised that pre-eligibility is required only for non-emergent procedures/medical expenses. If member requires emergent services, please proceed without submitting a pre-eligibility request and eligibility will be determined post-procedure

  
Pre-Eligibility vs. Provider Outreach

Which one do I need?

Pre-eligibility ensures that specific treatments are eligible for sharing before you receive them. Medical records are required for review.

Provider Outreach is for contacting your provider if they are unsure about accepting Impact Health Sharing.

  
Quick Links

Member Video Tips

Video1
What Is A Co-Share?
Video2
Going To The Doctor