PROVIDER ASSISTANCE FORM

If your provider is unsure or unwilling to accept Impact, please fill out the form below and we will reach out to educate them on how healthcare sharing works. The provider outreach is an educational call only. The call does not guarantee your provider will agree to bill Impact.

To ensure that our team can contact your provider, please make sure you have a scheduled appointment that is at least 72 hours after the submission of this form. We cannot conduct provider outreach on behalf of Prospective Members.

Note: If your upcoming appointment is for a procedure or surgery, please call 855-378-6777 instead.

Download our Provider Outreach Letter here

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Are you a new or established patient? *

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Member/Patient Name *

Patient DOB *

Member Phone Number *

Membership ID *

Name of Clinic/Facility In Which Provider Practices *

Provider Name *

Number or prompt for provider billing *

Provider Address

Name of Person Spoken To If You Have Contacted Provider (Optional)

Reason for Request *

Type of Service Needed *

Date of Upcoming Appointment *

Have you previously tried to get an appointment and been denied? If yes, why? *

Additional notes and details you would like to provide the team

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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.