CHA Bill Sharing Form - Diamond & Emerald
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Diamond and Emerald Plans

Self-pay Medical Bills Request for Sharing

* For members on the Diamond plan submit bills for incidents that exceed $1,000.
* For members on the Emerald plan submit bills for incidents that exceed $5,000.
* An incident is testing and/or treatment for a medical condition, injury, or illness.
* Eligible medical bills are shared by members who contribute to help bear the burden of other members’ health care costs.

Contact Information

In the spaces below enter the doctor’s diagnosis and explain the incident for which you are requesting assistance from the member sharing fund.
If the diagnosis is not on the detailed bill you might need to ask for the information from the doctor’s notes.

For Accidents

For Maternity

This information is recorded in clinic visit notes and OB ultrasound reports.

Record all bills submitted on page 2 of this form.

CHA is secondary to all other sources of reimbursement for a member’s medical bills, including any health insurance, liability insurance, worker’s compensation, or other aid programs in which the member participates, with the exception of Medicaid. Medical bills must be submitted to these sources first and all resources exhausted before bills will be considered for sharing.

I understand that self-pay medical bills eligible for sharing as incidents are reviewed and negotiated to establish fair pricing. For this reason it is important that members do not pay their bills on the date of service unless they are confident that the entire incident will be their responsibility to pay.