0106-0036-01 OE Change Form v1

Account Change Form
Please print or type in black or dark blue ink only. Please see instructions on reverse before completing this form.
Retain last copy for your records and use as a temporary ID.
A. TO BE COMPLETED BY EMPLOYER
________________________________________________________________
___________________________ – __________________________________
Company Name or Trust Fund Name
______________________________________________________
Purchaser Contact
B. REQUESTED CHANGE(S)
❏ Address Change (Complete Section C)
❏ Name Change (Complete Sections C and D)
Purchaser Number
Enrollment Unit Number (EU)
(______) __________________ (______) ______________________
Phone Number
Fax Number
❏ Add Dependent (Complete Sections C and E)
❏ Delete Dependent (Complete Sections C and E)
❏ Check here if new address
C. EMPLOYEE/SUBSCRIBER INFORMATION (Please complete all fields)
_______________________________________________________________________________________
___________________________________
Last Name
First Name
MI
Medical Record Number
____________________________________________________________ _____________________________ _______ ____________
Street Address
City
State
ZIP Code
–
–
____________________________________ (______) _____________________ (______) ______________________
Social Security Number
Day Phone
Evening Phone
D. NAME CHANGE
From: ________________________________________________________ To: ______________________________________________________________
Last Name
First Name
MI
Last Name
First Name
MI
E. LIST FAMILY MEMBERS TO BE ENROLLED/DELETED (Please attach additional sheet, if adding more than three dependents.)
Have any dependents ever been Kaiser Permanente members? If so, please indicate their Medical Record Number in the field below.
Spouse
❏ Add
❏ Delete
Dependent 1
❏ Add
❏ Delete
______________________
Medical Record No.
______________________________________________________________________
Last Name
First Name
MI
/
/
______________________________________________________ ______________
Reason for Add/Delete (See back of form)
Date of Birth
______________________
Medical Record No.
______________________________________________________________________
Last Name
First Name
MI
/
/
______________________________________________________ ______________
Reason for Add/Delete (See back of form)
Date of Birth
Dependent 2
❏ Add
❏ Delete
______________________
Medical Record No.
______________________________________________________________________
Last Name
First Name
MI
/
/
______________________________________________________ ______________
Reason for Add/Delete (See back of form)
Date of Birth
Dependent 3
❏ Add
____________________ ____________________
Social Security No.
Maiden/Other Name
❏ Spouse
❏ Male ❏ Female
❏ Domestic Partner
/
/
/
/
____________________
____________________
Event Date
Effective Date
____________________ ❏ Child ❏ Student
Social Security No.
____________________
❏ Male ❏ Female
Relationship
/
/
/
/
____________________
____________________
Event Date
Effective Date
____________________ ❏ Child ❏ Student
Social Security No.
____________________
❏ Male ❏ Female
Relationship
/
/
/
/
____________________
____________________
Event Date
Effective Date
❏ Delete
______________________ ____________________ ❏ Child ❏ Student
Medical Record No.
Social Security No.
____________________
______________________________________________________________________
❏
Male
❏
Female
Relationship
Last Name
First Name
MI
/
/
/
/
/
/
______________________________________________________ ______________
____________________
____________________
Reason for Add/Delete (See back of form)
Date of Birth
Event Date
Effective Date
Dependent(s)’ Address (if different from subscriber’s): ❏ Check here if all dependents are at the address below.
Name(s)
Address
City
State ZIP Code
I understand that, except for Small Claims Court cases and claims subject to a Medicare appeals procedure, any dispute between
myself, my heirs, 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, 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 my right to a jury
trial and accept the use of binding arbitration. I understand that the arbitration provision is contained in the Evidence of Coverage.
Subscriber Signature (Required for all changes)
TOP COPY–To Kaiser Permanente (CSC)
MIDDLE COPY–To be retained by purchaser
Date
BOTTOM COPY–To be retained by subscriber and used as temporary ID
Account Change Form Instructions
General instructions:
Instructions for completing Sections A through E:
1. Please print firmly and legibly in black or dark blue ink.
Section A: The employer must complete all fields to
ensure we have correct account and enrollment reason
information. The employer is responsible for confirming
all information submitted by the subscriber, especially
effective dates as they affect your Health Plan dues.
2. To be enrolled, you must reside within the ZIP codes
listed on the enclosed sheet.
3. The employer must complete Section A.
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 B
through E. See right column for detailed instructions.
6. Be sure to include the date and your signature at the
bottom of the form.
7. Once the form is complete (including Section A), the
subscriber should retain the last copy for their records
to use as a temporary ID card.
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 indicate the requested
change they are making to their account. They must then
complete the other sections indicated. Please print legibly
in black or dark blue ink.
Section C: The subscriber must always complete this
section, even when making minor changes to the account.
This ensures our information is current. Please mark the
box if your address is new. Always include your Medical
Record Number.
Section D: The subscriber should complete this section to
notify Kaiser Permanente of a name change. Include both
the prior name and the new name.
Section E: The subscriber should complete this section
when adding, updating, or deleting dependent information.
Include any prior last names for both spouse and
dependents. Include their Kaiser Permanente Medical
Record Number, if they have one. Include the reason
and event date for the dependent addition or deletion
from the table below.
Addition/Deletion Reasons and Event Dates
Add Dependent Reason
Event Date
Acquired Student Status
Date Student Status Was Obtained
Family Adoption
Date of Adoption
Loss of Coverage
Date Coverage Was Lost
New Spouse
Date of Marriage
Moved into Service Area
Move Date
Newborn Addition
Date of Birth
Open Enrollment
Open Enrollment Effective Date
Delete Dependent Reason
Event Date
Loss of Student Status
Date of Status Change
Divorce
Date of Divorce
Member Deceased
Date of Death
Delete Dependent(s)
Dependent Termination Date
Open Enrollment
Open Enrollment Effective Date
0106-0036-01