Medical Expense Form
Here you can submit a Medical Expense Form electronically. The video below explains the information needed to process the form. Please give us a call if you have any questions when submitting your information. We are here to help at 855-378-6777.
Medical Expense Form
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Description
Email *
Member that Incurred Expenses (Full Name) *
Membership ID *
Facility Name
Provider Name
Provider Phone Number
Provider Tax ID Number
Provider Billing Address
Provider Billing City
Provider Billing State
Provider Billing Zip
Provider Physical Address
Provider Physical City
Provider Physical State
Provider Physical Zip
If your bill has more than one diagnosis code (ICD Code) or procedure code (CPT Code), please select the + button to enter each code separately.
Description of Charge (Medical appointment, prescription drug, etc)
Diagnosis Codes (ICD9/ICD10 codes)
Procedure Codes (CPT Codes)
Date of Service From
Date of Service To
Amount Charged
Any Provider Discounts
Amount Paid by Member
Proof of payment attached?
Total Charged
Total Being Considered
Upload Attachments
Drag & drop a file to upload it.
Impact Health Sharing is a not-for-profit corporation that exists to create,
exercise, and express practical applications of Christian faith,
beliefs, and ethics. We believe in bringing together individuals
and families in shared acts of common good. Impact Health Sharing is not insurance. It is a not-for-profit organization and does not guarantee payment of members’ medical bills. Impact Health Sharing is not regulated as insurance. Certain states require health sharing organizations to publish a disclosure to more clearly be exempted from insurance regulation. While Impact Health Sharing is not insurance and therefore, need not necessarily qualify for such exemptions, Impact Health Sharing has elected to publish these exemptions. You can review the disclosure required for the state in which you reside here: View Disclosures.
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