CHA Direct Primary Care Enrollment Form – …Sharing makes a difference…

Christian Health Aid

Enrollment Form

Full Name *

Cell Number *

Home Number

Mailing Address *

City *

State *

Zip *

SECTION A

Please provide information for all family members whom you wish to enroll in the program. CHA Guidelines state that all family members, except those of age or living apart, must enroll unless they et one of the acceptable exceptions on Page 10, e.g., they have employer-paid job coverage, state aid, etc.

Applicants - Repeating

Name *

Gender *

Male

Female

Birth Date *

Social Security #

Add Remove

Please provide information for all family members whom you are NOT enrolling and your reason.

Not Enrolling Names - Repeating

Not enrolling - Name

Gender

Male

Female

Birth Date

Reason

Add Remove

SECTION B

Mark your sharing choice below *

Traditional Sharing

Diamond Care Sharing

Emerald Care Sharing

Traditional Dental Option

Add Dental Sharing Program - ($150 Annual Member Responsibility - $8000 Annual Maximum)

Traditional Vision Option

Add Vision Sharing Program - ($150 Annual Member Responsibility - $1000 Annual Maximum)

(Dental and Vision options are available with the Traditional Sharing only)

Diamond Extencare Option

Add ExtenCare - (ExtenCare is available with Emerald Care Sharing or Diamond Care Sharing only)

Emerald ExtenCare

Add ExtenCare - (ExtenCare is available with Emerald Care Sharing or Diamond Care Sharing only)

SECTION C

Effective Date to enter CHA: *

(must be the beginning of a month, and no earlier that the 1st day of the current month)

Other current health coverage (if any)

Effective Date

Have you previously been enrolled in CHA? *

Yes

Approximate date your membership was terminated?

SECTION D

Name of congregation where you currently have your membership:

SECTION E

If a 3rd party will be paying your monthly shares, please list them below:

3rd Party Name

Address

City

Zip

I wish to receive future sharing notices and other billing information (including ACH change notices) via:

Postal

I agree to receive occasional information from CHA via SMS or other electronic methods:

Yes

By signing below, I acknowledge that I understand the following points: (1) If I participate in the Traditional Sharing, medical providers should send my medical bills directly to CHA, and I will only self-pay if I’m required. If I participate in the Diamond Sharing or Emerald Sharing, CHA will not accept direct billing from providers (except for special situations agreed upon by CHA), but rather they will need to send the bills to me, and I will be responsible to send them to CHA with the proper self-pay documentation as per CHA’s Guidelines.
(2) I have read, and do accept, the HCSM disclosure for my state, found online at www.cha.faith under the “Application” tab, or at this link: https://theaidplans.us/cha-forms/HCSM_State_Disclosures.

Signature of Head of Household (or Person Responsible): *

Clear