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
Group number
Hire date (mm/dd/yyyy)
Effective enrollment/
change date (mm/dd/yyyy)
Enrollment unit
A. ENROLLMENT/CHANGE REASON (see Change Table for assistance)
New group: ❑ Yes ❑ No
❑ New Hire (complete sections A, B, C, D)
❑ 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
Email
C. FAMILY For additional dependents, attach a separate sheet with employee’s name at top. (Last, First, MI)
Social Security No.
❑ Add ❑ Delete ❑ Spouse ❑ Domestic partner
Gender ❑ M ❑ F
Spouse/domestic partner name:
Birth Date (mm/dd/yyyy)
Former last name (if any):
Medical Record No.
Social Security No.
❑ Add ❑ Delete ❑ Child ❑ Student
Gender ❑ M ❑ F
Dependent name:
Birth Date (mm/dd/yyyy)
Relationship:
Medical Record No.
Social Security No.
❑ Add ❑ Delete ❑ Child ❑ Student
Gender ❑ M ❑ F
Dependent name:
Birth Date (mm/dd/yyyy)
Relationship:
Medical Record No.
Social Security No.
❑ Add ❑ Delete ❑ Child ❑ Student
Gender ❑ M ❑ F
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, Inc., and Kaiser Permanente Insurance Company Arbitration Agreement*
I understand that (except for Small Claims Court cases, claims subject to a Medicare appeals procedure, and, if I am enrolled in coverage
that is subject to the ERISA claims procedure regulation, or any claims that cannot be subject to binding arbitration under governing
law) any dispute between myself, my heirs, relatives, or other associated parties on the one hand and Kaiser Foundation Health Plan, Inc.
(KFHP), Kaiser Permanente Insurance Company (KPIC),* any contracted health care providers, administrators, or other associated parties
on the other hand, for alleged violation of any duty arising out of or related to membership in KFHP or coverage by KPIC, 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 and in the Certificate of Insurance.
*Disputes arising from any of the following KPIC products are not subject to binding arbitration: 1) Tiers 2 & 3 of the Point-of-Service
(POS) Plan; 2), the Preferred Provider Organization (PPO) and Out-of-Area Indemnity (OOA) Plans; and 3), the KPIC Dental Plans.
Signature Required for all Kaiser Permanente Plans
(Excluding KPIC PPO, KPIC OOA, and KPIC Dental Plans)
88350
Revision date 09/2013
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.
88350
Revision date 09/2013