CHA Bill Sharing Form - Traditional Plan PageNextNext Traditional Sharing Self-pay Medical Bill Request for Sharing Eligible medical bills are shared by members who contribute to help bear the burden of other members’ health care costs. These bills remain the responsibility of the member and there is no guarantee any amount will be paid through sharing. Patient Name * Membership Number * Date of Birth * Contact Information Name of responsible party: * Home Phone Number * Cell Number Email Address Give the doctor's diagnosis for the bills you are submitting * Explain the reason for your visit to the hospital or clinic: * 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. Signature * Clear Next If you are human, leave this field blank.