CHA Bill Sharing Form
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2024 All Programs

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

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.