CHA Enrollment Form

Christian Health Aid

Enrollment Form

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

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 Sharing 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 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