NEEDS REQUEST Member Name* First Last Member Phone*Member Email* Need Type*Regular Needs RequestMaternity Needs RequestAlternative Medicine RequestSpecial Needs RequestPreventive Needs RequestSurgery Needs RequestAdditional Document Submission Preventive needs must be submitted by the provider within the PHCS network. Your provider can submit the request electronically or by mail. Click on the below PDF to learn more. Preventive Medical Sharing Other Coverage Medicare Medicaid Insurance plan Auto insurance (if auto accident) Select all that might apply.Please use this feature to submit additional documents for existing needsNeed Description*Please provide the details for your medical need to be shared with the community. Supporting Files (if any)Upload any supporting files for your medical need. Drop files here or Please include in your Regular Need Request: What happened in your own words When did you first start showing symptoms or require treatment? Currently on any medication for the condition? If yes, what is the condition(s)? Date(s) of service Follow up appointments expected for this medical need Provider(s) information, name & contact information Bills (itemized bills are best) if the provider has not sent us the claims directly Any detailed receipts of IUA payments made directly to providers Download Needs PDF What to include & what to expect: Any receipts or bills that you have received Estimated Delivery Date Name of OB/GYN and hospital (if known) Zion Health will be reaching out to you soon to help gather “Global Maternity” packages from your providers Download Maternity Needs PDF Please include in your Alternative Medicine Request: Requests for needs using alternative medicine may be eligible for sharing in the Zion Health community. When considering these important requests we take into account the following criteria: Provider information Cost associated with procedure or treatment Supporting documents of provider recommendation Descriptions of service being recommended What is the alternative treatment being requested alternative to? Special Need Requests: Requests can be made for needs that are not eligible to be shared with the Zion Health community. When considering these important requests from our members we take into account the following criteria: Amount of funds available in the “Additional Giving Fund” Length of continuous membership Supporting documents of provider recommendation Descriptions of service being recommended Future medical concerns if the member cannot receive the requested healthcare Number of current requests for use of these community funds Please submit any detailed information in your request that you feel will be helpful based on the above criteria CAPTCHA Enjoy Medical Cost Sharing Membership All of what you need in a medical cost strategy, great savings, and like-minded individuals. Enroll Online
