CHA Enrollment Form CHA Enrollment Form Please list the contact information for this account. Primary Contact Information Name * (First and Last Name) Phone * Phone Type * Mobile Landline Email Mailing Address * City * State * ABAKALARAZBCCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMBMDMEMIMNMOMSMTNBNCNDNENHNJNLNMNSNVNYOHOKONORQCPARISCSDSKTNTXUTVAVTWAWIWVWY Zip * Secondary Contact Information (Optional): Name (First and Last Name) Phone Phone Type Mobile Landline Email Relationship to Primary Contact Preferred Delivery Method for Billing Notices and Medical Bill Sharing Summaries: Email Postal Service Preferred Recipient for Billing Notices and Sharing Summaries: Primary Contact Secondary Contact Both For Email, Sharing Summaries are sent each day a bill is processed by default. For Postal Service, Sharing Summaries are sent once a month by default. I agree to receive occasional information from CHA via SMS or other electronic methods: Yes No 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 meet 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 # plus1 Add Another Person minus1 Remove This Person SECTION B 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 plus1 Add Another Person minus1 Remove This Person SECTION C Choose your Medical Program * Program One Program Two Program Three For information about each program, please go to the menu above and select Program Information -> Sharing Details or Rates and Calculator Program 1 Details Annual Medical Bill Sharing Limit: $50,000 Medical Bill Sharing Percentage after AMR/AFR: 70% Annual Member Responsibility (AMR): $5,000 Annual Family Responsibility (AFR): $10,000 Maximum Number of Contributions per Family: 6 *Those with Medicare A & B will have half of the listed Annual Member Responsibility (AMR) and Annual Family Responsibility (AFR) Amounts Program 2 Details Annual Medical Bill Sharing Limit: $100,000 Medical Bill Sharing Percentage after AMR/AFR: 75% Annual Member Responsibility (AMR): $2,500 Annual Family Responsibility (AFR): $5,000 Maximum Number of Contributions per Family: 6 *Those with Medicare A & B will have half of the listed Annual Member Responsibility (AMR) and Annual Family Responsibility (AFR) Amounts Program 3 Details Annual Medical Bill Sharing Limit: $150,000 Medical Bill Sharing Percentage after AMR/AFR: 80% Annual Member Responsibility (AMR): $1,000 Annual Family Responsibility (AFR): $2,000 Maximum Number of Contributions per Family: 6 *Those with Medicare A & B will have half of the listed Annual Member Responsibility (AMR) and Annual Family Responsibility (AFR) Amounts Choose Optional Dental and/or Vision Additions: Dental Sharing Add Dental Sharing Program Vision Sharing Add Vision Sharing Program Dental Sharing Program Annual Bill Sharing Limit: $8,000 Bill Sharing Percentage after AMR: 80% Annual Member Responsibility (AMR): $150 Additional Surgery AMR: $400 Additional Orthodontic AMR: $400 Vision Sharing Program Annual Bill Sharing Limit: $1,000 Bill Sharing Percentage after AMR: 80% Annual Member Responsibility (AMR): $150 Select this checkbox if you would like your children ages three and under to be excluded from your Optional Additions Selection(s) above SECTION D Enrollment Date is the first day of the month following the date the enrollment form is submitted, unless the member specifies a future month. Effective Date is the first day coverage begins. New memberships are subject to waiting periods following the Enrollment Date as follows, unless an allowable exception applies (see Program Guidelines for the list of allowable exceptions): Medical: 60 days Dental: 1 year Vision: 1 year Enrollment Date Selection Standard (1st of the following month) Future Enrollment Date “On the same date that employer-coverage or state aid ended (to prevent lapse of coverage). Future Enrollment Date JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Select a month later than next month. Waiting periods begin on the first day of the month selected. Reason for Future Enrollment * Enrollment Date Medical Start Date Dental and Vision Start Date Have you had other health coverage in the past 60 days? * Yes No Please list the name/type of coverage * Was/Is this coverage provided by your employer (Does not include self-employed)? * Yes No Is your coverage still in effect? * Yes No Please list the termination date Other Coverage Termination Date Have you previously been enrolled in CHA? * Yes No Are you a U.S. resident? * Yes No If not, what is your reason for enrolling in CHA? * SECTION E Name of congregation where you currently have your membership: * SECTION F If a 3rd party will be paying your monthly contributions, please list them below: 3rd Party Name Address City ST AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Zip By signing below, I acknowledge that I understand the following points: (1)Medical providers should be shown my CHA card and asked to send my medical bills directly to CHA, and I will only self-pay if I’m required, or if this has been otherwise arranged with CHA. (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): * signature keyboard Clear Submit If you are human, leave this field blank.