Pre-Notification

Christian Care Medi-Share
P.O. Box 120099
West Melbourne, FL
32912-0099
Member Relations: 1 (800) 264-2562

Please note: Completion of this form is only used to update ongoing needs previously reported on the Needs Notification Form. Prenotification is required prior to any medical procedure, referral to a specialist, or hospitalization. Completing this form is not sufficient to determine a need's eligibility for sharing.

Head of Household Name (as it appears on Membership Card)
Household Number (as it appears on Membership Card)
Effective Date (as it appears on Membership Card)
Home Phone Number (including area code)
Phone Number best to reach you (including area code) ext:
Patient Name
Patient Date of Birth
Describe illness or injury:
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If injury, when, where and how did it occur?
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Specify the medical treatment required: 
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When will treatment take place? 
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Name of doctor or hospital:  
Are they a PHCS provider? (Search PHCS)
Doctor or hospital's phone number: (including area code)  

If you are planning to schedule an elective surgical procedure or hospitalization, a pre-eligibility review is advised and in some cases required. Please refer to the Program Guide Section VIII I) "Medical Procedures Requiring Pre-eligibility Determination". To speak with a Member Advocate to begin the review process, please call 800-264-2562 Monday-Friday 9:00am-5:00pm eastern time.

Thank you for completing your requirement of "Pre-Notification" as outlined in the Program Guide Section VI. If you are having a problem completing this form and would prefer to call your Member Advocate line directly, please call
(800) 264-2562.