CHA Enrollment Form

Christian Health Aid

Enrollment Form


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

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

Not Enrolling Names - Repeating


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


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



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

I wish to receive future sharing notices and other billing information (including ACH change notices) via:
I agree to receive occasional information from CHA via SMS or other electronic methods:
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 under the “Application” tab, or at this link: