Pre-Eligibility Form

Request for Pre-Eligibility Review

Please allow 3-5 business days for the sharing determination to be made. For urgent requests, please select urgent request below. 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.

Urgent Request (response within 72 hours)

Email address for confirmation of Pre-Eligibility request *

Membership ID *

Member First Name *

Member Last Name *

Member DOB *

Facility Name *

Facility Address 1 *

Facility Address 2

Facility City *

Facility State *

Facility Zip *

Facility Tax ID *

Facility Phone # *

Facility Fax #

Provider's Full Name *

Provider NPI *

Provider Tax ID *

Provider Phone # *

Provider Fax #

Provider Contact *

Diagnosis or Chief complaint *

CPT codes/Services to be rendered *

If maternity:

LMP (Last menstrual period date)

EDD (Estimated due date)

Date of Service

Email or fax number where eligibility response is to be sent *

Please provide patient's medical records pertaining to this pre-authorization request

Drag & drop a file to upload it.

Guidelines | Share Your Story

Providers | Help Center | Contact Us

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.