Diabetic Supplies Benefit Enrollment

Diabetic Supplies Benefit Enrollment Form

CHA has a program to share diabetic supply expenses based on the amount of expenses incurred according to the terms outlined below. If you qualify for this benefit and wish to be enrolled in the program you may complete and sign this form and return it to the above address.

  • Once a member is enrolled in the program, we will process shared amounts every month without requiring additional monthly submission 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.
  • CHA members will share up to $300.00 per month for diabetic expenses for insulin dependent (Type 1) diabetic members.
  • CHA members will share up to $150.00 per month for diabetic expenses for non-insulin dependent (Type 2) diabetic members.
  • Please fill out the section below using a separate line for each product listed on the receipt. Please indicate the product, place of purchase, cost, number of days the supply lasts, and the cost per month. Please include receipts for at least one month’s diabetic supplies. We cannot process your enrollment without receipts. Do not hesitate to call if you have questions regarding this enrollment.

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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