Forms for Managing Your Membership

Submit a Medical Need

Complete this form to process medical needs for all accidents and injuries

Reimbursement Submission Form

Manage Your Membership

Billing Information Form
Submit/update billing information for automatic contributions

Needs Processing Form
Submit additional medical need information.

Adoption Assistance Needs Processing Request
Itemize eligible adoption expenses for membership sharing

Membership Changes

Membership Update Form
Submit any new information or changes to your membership

The following must be completed online.

Add/Remove Dependents
Please login in to your Member Portal by clicking Sign In. If you can not access the new portal, please call us at 1.888.244.3839 so we can enable it for you. This will allow you to add or remove dependents.

Cancellation Requests
Please call us at 1.888.833.1408 Monday through Friday 8am to 6pm CST.

HIPAA Release Form
Sign the release form using DocuSign. This will open a new browser window and walk you through authentication.

Requested changes must be received by the 25th of the month to allow time for processing. Approved changes go into effect on the 1st of the following month.

Filling and Signing

You may fill and sign any of our forms and email them using the free Adobe Acrobat Reader.
Please follow these instructions to add your signature before sending.

Annual Membership Commitment

Each year, all members of the household age 18 and over must submit a Membership Commitment Form acknowledging their continued commitment to the:

  • Altrua HealthShare Membership
  • Statement of Standards
  • Acknowledgments section of the Membership Enrollment Application
  • Escrow Instructions for sharing of Member contributions

Complete Online—It’s Easy!

Primary Member Dependents (18+)

Download PDFs to send via email, fax or mail:

Membership Commitment Form
For Primary Member and Household

Membership Commitment Form — Dependents
For Dependents Age 18 and Older