California Region Group Enrollment/Change Form

California Region Group Enrollment/Change Form
Please print or type in black ink only. See instructions on reverse before completing this form. Make a copy for your records.
TO BE COMPLETED BY EMPLOYER
Company name
Hire date (mm/dd/yyyy)
Group number
Effective enrollment/
change date (mm/dd/yyyy)
Enrollment unit
A. ENROLLMENT/CHANGE REASON (see Change Table for assistance)
❑ New Hire (complete sections A, B, C, D)
New group: ❑ Yes ❑ No
❑ Open Enrollment (complete sections A, B, C, D)
Health Plan (Check one) ❑ HMO Plan ❑ Deductible Plan ❑ Other
❑ Loss of Other Coverage (complete sections A, B, C, D)
❑ Other (please specify)
❑ Name change (complete sections A, B, C, D) From:
To:
Event Date (mm/dd/yyyy)
B. EMPLOYEE Have you ever been a Kaiser Permanente member? ❑ Yes ❑ No
Medical Record No. (if known)
Social Security No.
Name (Last, First, MI)
Birth Date (mm/dd/yyyy)
Home Address
City
Work Phone
Home Phone
Ethnicity
Preferred Language
Gender
State
❑M
❑F
ZIP
E-mail
C. FAMILY For additional dependents, attach a separate sheet with employee’s name at top. (Last, First, MI)
❑ Add ❑ Delete ❑ Spouse ❑ Domestic partner
Gender
❑M
❑F
Social Security No.
Spouse/domestic partner name:
Birth Date (mm/dd/yyyy)
Former last name (if any):
Medical Record No.
❑ Add ❑ Delete
❑ Child
❑ Student
Gender
❑M
❑F
Social Security No.
Dependent name:
Birth Date (mm/dd/yyyy)
Relationship:
Medical Record No.
❑ Add ❑ Delete
❑ Child
❑ Student
Gender
❑M
❑F
Social Security No.
Dependent name:
Birth Date (mm/dd/yyyy)
Relationship:
Medical Record No.
❑ Add ❑ Delete
❑ Child
❑ Student
Gender
❑M
❑F
Social Security No.
Dependent name:
Birth Date (mm/dd/yyyy)
Relationship:
Medical Record No.
Do any of dependents above live at another address? ❑ Yes ❑ No If yes, complete the following:
Name (Last, First, MI):
Address:
D. Kaiser Foundation Health Plan Arbitration Agreement: I understand that (except for Small Claims Court cases, claims subject
to a Medicare appeals procedure, and, if my Group must comply with ERISA, certain benefit-related disputes) any dispute between
myself, my heirs, relatives, or other associated parties on the one hand and Health Plan, its health care providers, or other associated
parties on the other hand, for alleged violation of any duty arising out of or related to membership in Health Plan, including any claim
for medical or hospital malpractice (a claim that medical services were unnecessary or unauthorized or were improperly, negligently,
or incompetently rendered), for premises liability, or relating to the coverage for, or delivery of, services or items, irrespective of
legal theory, must be decided by binding arbitration under California law and not by lawsuit or resort to court process, except as
applicable law provides for judicial review of arbitration proceedings. I agree to give up our right to a jury trial and accept the use
of binding arbitration. I understand that the full arbitration provision is contained in the Evidence of Coverage.
Employee/Applicant signature
*Additional documentation may be required.
0106-0040-04-r03
Revision date 02/2008
Date
Employer signature
Date
California Region Group Enrollment/Change Form
General instructions
1. Please print firmly and legibly in black ink.
Instructions for completing employer and new
enrollment sections and sections A through D:
2. To enroll, the subscriber must reside or work within
one of the ZIP codes listed on the enclosed sheet.
To be completed by employer: The employer must
complete all fields to ensure we have correct account
and enrollment information.
3. The employer must complete the first section titled
“To be completed by employer.”
Section A: The subscriber must complete this section.
4. The employer is responsible for confirming all information
prior to submitting, especially effective dates, as these affect
your Health Plan dues.
5. The employee/subscriber must complete Sections A and B.
See right column for detailed instructions.
6. Be sure to sign and date the bottom of the form.
7. Once the form is complete (including employer section),
the subscriber should make a copy for his or her records,
and to use as a temporary ID card, after the effective date.
8. All changes to accounts, including effective dates and child or
student status, will be made in accordance with the contractual
agreement between the purchaser and Kaiser Permanente.
Section B: The subscriber must always complete this section.
Use the Change Table (below) for assistance.
Section C: The subscriber must indicate the requested change
to the account and complete all fields for any dependents
being enrolled. We will verify the eligibility of these dependents
during the enrollment process. Be sure to include any former
last names for both spouses and dependents. Also indicate
the appropriate role. The student role should be marked only if
the dependent qualifies as an “overage dependent” attending
school. Please contact your employer regarding rules for overage
dependent students. A completed Student Certification form
may be required.
Section D: The subscriber must sign and date this section.
Change Table
Add dependent
Event date
Acquired student status*
Student status date
Family adoption*
Adoption date
Loss of coverage
Coverage loss date
New spouse (marriage)
Marriage date
Moved into service area
Move date
Newborn addition
Birth date
Open enrollment
Open enrollment effective date
Delete dependent
Event date
Loss of student status
Status change date
Divorce
Divorce date
Member deceased*
Death date
Delete dependent(s)
Dependent termination date
Open enrollment
Open enrollment effective date
Demographic Change
Event date
Address change, telephone number change
Status change date
Demographic (name, birthdate, social security number) change
Status change date
*Additional documentation may be required.
0106-0040-04-r03
Revision date 02/2008