CHA Enrollment Form Christian Health Aid Enrollment Form Full Name * Phone Number * Fax Number Email Mailing Address * City * State * AB AK AL AR AZ BC CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MB MD ME MI MN MO MS MT NB NC ND NE NH NJ NL NM NS NV NY OH OK ON OR QC PA RI SC SD SK TN TX UT VA VT WA WI WV WY 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 have employer paid job coverage or state aid. Applicants - Repeating Name * Gender * Male Female Birth Date * Age * Social Security # Add Remove Other Coverage Other current health coverage Effective Date SECTION B Have you previously been enrolled in CHA? * Yes No Approximate date your membership was terminated? Effective Date to enter CHA: * (must be the beginning of a month, and no earlier that the 1st day of the current month) SECTION C Name of congregation where you currently have your membership: SECTION D Mark your sharing choice below * Traditional Sharing Emerald Care Sharing Diamond Care Sharing Traditional Addins Add Dental Sharing Program - ($150 Annual Member Responsibility - $1000 Annual Maximum) Traditional Addins Add Vision Sharing Program - ($150 Annual Member Responsibility - $1000 Annual Maximum) (Dental and Vision options are available with the Traditional Sharing only) ExtenCare Add ExtenCare - (ExtenCare is available with Emerald Care Sharing or Diamond Care Sharing only) SECTION E If a 3rd party will be paying your monthly shares, please list them below: Name Address City ST AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip By signing below, I acknowledge that I understand the following points: If I participate in the Traditional Sharing, medical providers are free to send my medical bills directly to CHA. If I participate in the Diamond Care Sharing or Emerald Care Sharing, CHA will not accept direct billings from providers, but rather they will need to send the bills to me and I will be responsible to forward them to CHA with the proper self-pay documentation as per CHA's Guidelines. I have read and accepted the disclosure for my state. https://theaidplans.us/cha-forms/HCSM_State_Disclosures Signature of responsible party * Clear Submit