COVID-19 Medical Freeze Form

Suspend your membership for up to 12 months at no charge. We are currently waiving the health-care provider authorization for any concern/ medical issue related to COVID-19. When the crisis is over and you feel comfortable participating in Summit programming once again, simply give us a call and we will reactivate your account; no hassle, no charge.

Please note, all requests for freezes must be submitted before Thursday, June 25, 5:00 PM to be made effective July 1, 2020.

Please note:
  Requests received after Thursday, June 25, 2020 will NOT be processed for July and will be made effective for August 1, 2020. 

All other Medical Freezes must complete the Medical Freeze form and have it signed by a Health Provider. Please contact Member Services with questions, 406.751.4107.

Facility *


Today's Date *

Member First Name *

Member Last Name *

Email Address *

Freeze Start Date *

Freeze End Date (if known, not required)

Reason for Medical Freeze *