CHA Enrollment Form

Christian Health Aid

Enrollment Form

SECTION A

Applicants - Repeating

Other Coverage

SECTION B

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

SECTION C

SECTION D

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

SECTION E

If a 3rd party will be paying your monthly shares, please list them below:
By signing below, I acknowledge that I understand the following points: If I participate in the Traditional Plan, medical providers are free to send my medical bills directly to CHA. If I participate in the Diamond Care or Emerald Care, 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.