Needs Notification Form (NNF)

Use this form to begin the processing of the bills for your medical event. Only one NNF is needed per medical event. Providers should be directed to send their bills directly to the processing center on form UB-04 for hospitals or CMS 1500 for other providers.

**Please fill out this form completely; as an incomplete form may delay sharing. If you need assistance, call Member Services at (800) 264-2562.**

You should only fill out this form for a new medical event, there is no need to submit for a subsequent visit related to the same medical event.
However, you may want to submit this medical bill for sharing solely for the purpose of obtaining a discount.  In that case, please complete this form, answering yes to the question below, but be aware if the bill is not eligible for sharing, it will not be applied to your AHP or IMR.
Are you submitting this form only for the purpose of a possible discount?   
Section I
Household number on card  
Head of Household Name First:    Last:  
Head of Household SSN  
  000-00-0000
Effective date on card    
  mm / dd / yyyy
Home Phone # () -      
Work Phone # () -
Cell Phone # () -
Email Address
For your convenience we can communicate by email which helps expedite the process. Please be aware that some of these emails may include your personal information, as well as confidential medical details. Information transmitted by email is NOT secure.
I give Christian Care Ministry my permission to send my personal medical information by email.
 
Mailing Address
Street Address:  
City:
 
State:
 
Zip:
+  
   +4 for PO Box

Patient Name First:     Last:  
Patient Date Of Birth
     
  mm / dd / yyyy
Relationship to Head of Household
 
Marital Status of the Patient
 
Section II
  • Is the patient an adult child?
     
    If yes, please fill out the Adult Dependent Eligibility Form and describe below the circumstances of illness or accident.
  • Is there insurance or any other resource available to pay all or part of the medical bills, such as workers' compensation, property owner's liability insurance, health insurance, foundations, service organizations, or governmental programs?
     
    If yes, list the insurance and/or other resource name(s), policy number(s) and phone:

    If your answer is yes, please fax the following documentation to: (321) 722-5138.
       A) Copy of your benefit plan and insurance card.
       B) Documentation of the effective date (and term date, if any) of this benefit.
       C) The names of the family members who are covered.
  • Is any family member eligible for Medicare or Medicaid?
      If your answer is yes, please fax the following documentation to: (321) 722-5138.
       A) Copy of your Medicare or Medicaid card.
       B) Documentation of the effective date (and term date, if any) of this benefit.
       C) The names of the family members who are covered.
 
Section III
  • Please select the type of medical event from the list 

Primary Physician
Name of Physician: Type of Physician:  
Street Address:
City:  State:  Zip:
Physician's Phone:  
Are they a PHCS network provider (click here if you don't know)?  
Specialist
Name of Specialist: Type of Specialist:
Street Address:
City:  State:  Zip:
Specialist's Phone:
Are they a PHCS network provider (click here if you don't know)?
Hospital
Hospital Name:
Street Address:
City:  State:  Zip:
Hospital's Phone:
Are they a PHCS network provider (click here if you don't know)?


**Penalties may apply if you choose to utilize a non-PHCS provider.

Section IV
Have you paid any amount to providers for this medical event?  
Remember: Payment up front is not required. Please use the Reimbursement form found online at www.MyChristianCare.org to document any out of pocket expenses (not your provider fee).

Initial Member Responsibilities and Annual Household Portions are applied at the time the bill is processed, not the date of service.

If yes, then please provide Date of Service, Provider Name, Provider Phone Number, and Amount Paid:

Needs Notification Section


By typing in my full name in the following field, I certify that I have read and understand the Medi-Share Guidelines Section II. Membership Qualification and that I and the patient continue to qualify for membership in the Medi-Share program under those guidelines.  I also certify that I (and the patient if applicable) continue to profess the statement of faith and am living pursuant to the Christian lifestyle requirements outlined in the guidelines (Section II. A. Christian Testimony).

Participant name or name of patient 18 years or older  
Date         
           mm / dd / yyyy