CHA Direct Primary Care Enrollment Form Christian Health Aid Direct Primary Care Enrollment Form The DPC program will share 50% of Direct Primary Care charges in monthly payments for all CHA members. If you are on Direct Primary Care and would like CHA to share this cost with you, please complete and sign this form and return it to the above address along with a bill showing your monthly DPC expenses. Full Name * CHA Membership Number * Cell Phone * Home Phone Email Mailing Address * City * State * Zip * Please provide information for all family members on your CHA membership who are on your DPC membership. Applicants – Repeating Name * DPC Monthly Cost * plus1 Add Another family member minus1 Remove By signing below, I certify that this is an ongoing monthly expense for primary medical care, and I will inform CHA if my DPC membership changes or is cancelled. I understand that I must apply for sharing from the DPC Program each year. I have attached documentation showing my DPC charges per month. Signature of responsible party * signature keyboard Clear File Upload * Drop a file here or click to upload Choose File Maximum file size: 134.22MB If you are human, leave this field blank. Submit