CHA Bill Sharing Form - Diamond & Emerald PagePagePage Diamond Care and Emerald Care Sharing Self-pay Medical Bills Request for Sharing * For members on the Diamond Care Sharing submit bills for incidents that exceed $1,000. * For members on the Emerald Care Sharing 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. * Members remain responsible to pay their own medical bills. There is no guarantee that any bill submitted for sharing will receive any payment from the ministry. Patient Name * Membership Number * Date of Birth * Contact Information Name of responsible party: * Home Phone Number * Cell Number Email Address Incident Details In the spaces below enter the doctor’s diagnosis and explain the incident for which you are requesting assistance from the member sharing fund. Doctor's diagnosis * NOTE: If the diagnosis is not on the detailed bill you might need to ask for the information from the doctor’s notes. When did the symptoms or treatment for this condition begin? * Details of incident * For Accidents When did the accident occur? Is there any liability, worker’s compensation, or other insurance with benefits for the bills relating to this accident? Yes No Please indicate the type of benefit and name of the provider: * For Maternity What is the expected delivery date? 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. Signature * Clear Next If you are human, leave this field blank.