CHA Bill Sharing Form - Traditional Plan
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Traditional Plan

Self-pay Medical Bills Request for Sharing

Eligible medical bills are shared by members who contribute to help bear the burden of other members’ health care costs.

Contact Information

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.