Retroactive Membership Request Form

Retroactive Membership Request Form
CSC RECEIPT DATE
TODAY’S DATE
Customer: Complete this form to request retroactive membership changes which exceed the contractual retroactive time
limit. Complete Sections One, Two, and Three. Submit the completed form to your Account Administration Representative
(AAR) at the California Service Center (CSC). Please attach the appropriate documentation to substantiate the retroactivity
request.
SECTION ONE—CUSTOMER INFORMATION
Customer name:
Customer number: (e.g., 12345-0001)
Customer contact information:
Name:
Title:
Telephone:
Fax:
Retroactive enrollment(s)?
Retroactive reinstatement(s)?
Retroactive termination(s)?
Retroactive transfer(s)?
Explanation for this retroactivity request:
Address:
City/State:
E-mail address:
Is this a KPIC group? Yes
Payment included? Yes
No
If no, estimated payment/report date:
ZIP code:
No
SECTION TWO—MEMBER INFORMATION
Employee (subscriber) name
SSN / MRN
SECTION THREE—CUSTOMER ACKNOWLEDGEMENT
Dependent name
Action requested
Effective date
( not required if completed by CSC)
I hereby request that Kaiser Permanente waive the retroactive time limit for the member(s) listed on this form. I understand
that Kaiser Permanente may decline this request for some or all of these member(s). I confirm that all attached documents
in support of this request are true and complete. I understand that I must make payment for all months a member is added
retroactively, if applicable.
I have read and agree with the above retroactive policy
0553-0156-01-r04
Date:
CA REGION USE ONLY