CHA Direct Primary Care Enrollment – …Sharing makes a difference…

CHA Direct Primary Care Enrollment Form

Christian Health Aid

Direct Primary Care Enrollment Form

Full Name *

CHA Membership Number *

Cell Phone *

Home Phone

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 *

Add Another family member Remove

By signing below, I certify that this is an ongoing monthly expense, and I will inform CHA if I cancel my DPC membership. 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 *

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