CHA Direct Primary Care Enrollment Form

Christian Health Aid

Direct Primary Care Enrollment Form

Please provide information for all family members on your CHA membership who are on your DPC membership.

Applicants – Repeating

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.