Membership Change Request: Integrative Family Medicine of Asheville
Please Read Before Completing this Form:
  • All membership cancellation and hold requests must be submitted through this form. To ensure both parties receive a record of the cancellation response, our staff is not authorized to process cancellations/holds verbally. 
  • The limit for membership holds is three (consecutive) months per year, and number of months on hold will be added to the end of the membership year to = 12 total months. *Memberships carrying a balance are ineligible to be placed on hold. 
  • You may access your membership contract/s and invoices by following the prompts to your Hint Health dashboard here. 
  • Please click here to view common services, fees, and savings.

Sign in to Google to save your progress. Learn more
Email *
Full Name *List only one member per submission *
Membership start date (month/year) or date of last annual visit, if you have been enrolled for more than a year. Please enter your best guess, even if you are unsure. Our front desk staff will confirm this information and process your request with the correct dates on file. *
MM
/
DD
/
YYYY
Are your requesting a membership hold or cancellation? *Hold limit of three (consecutive) months/year. *
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of Integrative Family Medicine of Asheville. Report Abuse
Google Forms