CHA Enrollment Form 2024 CHA Enrollment Form 2024 Christian Health Aid Enrollment Form Full Name * Cell Number * Home Number Email Mailing Address * City * State * ABAKALARAZBCCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMBMDMEMIMNMOMSMTNBNCNDNENHNJNLNMNSNVNYOHOKONORQCPARISCSDSKTNTXUTVAVTWAWIWVWY 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 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 Program Four For information about each program, please go to the menu above and select Program Information -> 2024 -> 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: 80% 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 Program 4 Details Annual Medical Bill Sharing Limit: $200,000 Medical Bill Sharing Percentage after AMR/AFR: 90% Annual Member Responsibility (AMR): $500 Annual Family Responsibility (AFR): $1,000 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 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 Effective Date to enter CHA: * (must be the beginning of a month, and no earlier that the 1st day of the current month) Other current health coverage (if any) If your other current health coverage is set to terminate, when is the termination date? Other Coverage Termination Date Have you previously been enrolled in CHA? * Yes No SECTION E Name of congregation where you currently have your membership: * SECTION F If a 3rd party will be paying your monthly shares, please list them below: 3rd Party Name Address City ST AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Zip I wish to receive future sharing notices and other billing information (including ACH change notices) via: Email Postal service I agree to receive occasional information from CHA via SMS or other electronic methods: Yes No 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 If you are human, leave this field blank. Submit