Diabetic Supplies Benefit Enrollment

Diabetic Supplies Benefit Enrollment Form

Christian Health Aid has a program to share diabetic supply expenses based on the amount of actual expenses incurred. Expenses for non-insulin dependent members may be shared based on reported expenses up to $150.00 per month. Expenses for insulin dependent members may be shared based on reported expenses up to $300.00 per month.

To make the diabetic supplies sharing benefit easy to use we are requesting all program members who routinely use diabetic supplies to complete this enrollment. Once a member is enrolled in the program we will process shared amounts every month without requiring additional monthly submissions of bills. Shared amounts will be processed monthly even though supplies may be purchased several months at a time. Once a year you will be required to renew your diabetic supplies benefits by providing receipts of one month’s expenditures.

Please read carefully the conditions of enrollment as stated below. If you qualify for this benefit and wish to be enrolled in the program you may complete and sign the form and return it to the above address.

Please remember to include receipts for one month’s diabetic supplies. We cannot process your enrollment without these receipts.

List Medical Supplies

Product Place of Purchase Purchase Price as Shown on Receipt No. Days Supply Cost Per Month
$
$
$
$
$
$
$
$
$
$
$
I certify that I am or my dependent designated below is a diabetic and that he/she is the type I have indicated.

I have attached receipts that represent one month’s diabetic supplies.


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