CHA Bill Sharing Form - All Programs - DNU
  • Page
  • Next

All Plans

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.

Contact Information

Request Type

For Accidents

For Maternity

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.