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. Retain last copy
for your records and use as a temporary ID after the effective date. (See * footnote on reverse.)
TO BE COMPLETED BY EMPLOYER
Company name
Date of hire
Group number
Enrollment unit
Effective date of enrollment or coverage
NEW ENROLLMENT Check one:
❑ New purchaser
❑ New hire (complete sections A, B, C, D)
❑ Loss of other coverage (complete sections A, B, C, D)
PLAN Check one:
❑ HMO
❑ Deductible Plan
❑ Open enrollment (complete sections A, B, C, D)
❑ Other (please specify)
Date of event
IF MAKING A CHANGE, COMPLETE THE FOLLOWING:
❑ Add dependents (complete sections A, B, D)
❑ Delete dependents (complete sections A, B, D)
*Reason:
(see Change Reason Table) Event date:
❑ Name change (complete sections A, B, D) From:
To:
❑ Address (complete section A)
❑ Telephone (complete section A)
A. EMPLOYEE INFORMATION
Name (Last, First, MI)
Former last name (if any)
Home address
Apt. no. City
Home phone
❑M ❑F
Gender
E-mail
Work phone
State
ZIP
Medical Record no. (if known)
Social Security no.
Date of birth
Preferred spoken or written language (optional) Ethnicity (optional)
B. FAMILY INFORMATION For additional dependents, attach a separate sheet and please put the
employee’s name at the top. (Last, First, MI)
❑ Add ❑ Delete
❑ Spouse ❑ Domestic partner
Spouse/Domestic partner name:
Former last name (if any):
❑ Add ❑ Delete
❑ Child ❑ Student
Social Security number
Date of birth
Medical Record number
Gender
Social Security number
Date of birth
Medical Record number
Gender
Social Security number
Date of birth
Medical Record number
❑M ❑F
Dependent name:
Relationship:
❑ Add ❑ Delete
Gender
❑M ❑F
❑ Child ❑ Student
❑M ❑F
Dependent name:
Relationship:
Do any of your dependents above live at another address? ❑ Yes ❑ No If yes, complete the following:
Name(s) (Last, First, MI):
Address:
C. OTHER COVERAGE INFORMATION:
Including yourself, do any of the persons listed above have other coverage? ❑ Yes ❑ No
Name
Insurance carrier name
Policy no./Effective date
Phone no.
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
Employee Retirement Income Security Act regarding certain benefit related disputes) 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 full Arbitration
provision is contained in the Evidence of Coverage.
Employee/Applicant signature
*Additional documentation may be required.
White copy - Kaiser Permanente
Date Employer signature
Yellow copy - Employer
Pink copy - Employee
Date
California Region Group Enrollment/Change Form
General instructions:
1. Please print firmly and legibly in black ink.
2. To be enrolled, you must reside within one of
the ZIP codes listed on the enclosed sheet.
3. The employer must complete the first section
labeled “To be completed by employer.”
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 through C. 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 completed
employer section), the subscriber should retain
the last copy for their records 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.
Instructions for completing employer and new
enrollment sections and sections A through D:
To be completed by employer: 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 the Health Plan dues.
If making a change, 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.
Section A: The subscriber must complete this
section.
Section B: The subscriber must indicate the
requested change they are making to their 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 only be
marked if the dependent qualifies as an “overage
dependent” attending school. Please contact your
employer regarding their rules for overage
dependent students. A completed Student
Certification Form may be required.
Sections C, D: The subscriber must complete
these sections.
Change Reason Table
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 (marriage)*
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
*Additional documentation may be required.
0106-0040-01-r03