Kaiser Permanente: Account Change Form, California, 2016

Kaiser Permanente for Individuals and Families
ACCOUNT CHANGE FORM
California
Instructions
There are different types of plan and account changes you can make with this form. Please fill out your information in Section A. Next, select your enrollment
period in Section B. Then, look at the options in Section C and complete the section(s) for the plan or account change(s) you would like to make. To avoid
being billed twice, if you are enrolled in a plan through Covered California, you must cancel your current plan on or before the effective date of the new
plan you are enrolling in.
A. Fill Out Your Information Fill this out if you are the subscriber/new subscriber or person responsible for payment.
™ Check here if your address or phone numbers have changed.
First name
MI
Last name
Medical record number
Home address
City
State
ZIP
Billing address (™ Check if the same as the home address.)
City
State
ZIP
Phone
Social Security number
B. When Are You Making a Change?
To make a plan or account change (except for ending coverage), you must either be in the annual open enrollment period or in a special enrollment
period. For more about special enrollment periods, including authorized paperwork that you may need to submit, see the Enrolling During a Special
Enrollment Period guide. Please select only one:
™
I am making a change during open enrollment.
I am making a change during a special enrollment period.
™
If you selected “a special enrollment period,” please check the circle next to the event that triggered the special enrollment period and include the date of your triggering event: ______/______/______
™ Loss of health care coverage
™ Gaining or becoming a dependent through marriage
™
Gaining a dependent through the birth of a child, adoption, or foster care
™ Losing a dependent through divorce or legal separation
™ Death of the subscriber or a dependent
™ Court order
™ Permanent relocation
™ Release from incarceration
™
Change in eligibility for federal financial assistance through
Covered California
™ Change in eligibility for employer health coverage
™ Determination by Covered California
™ Misinformation about coverage
™ Provider network changes
™ Grandfathered plan renews outside open enrollment
C. What Change(s) Do You Want To Make?
Please check the circles for the changes you wish to make, and on the next page, list each family member who is affected. If there are other members on
your account who are not listed, we will not make any changes for them.
™
I am ending my coverage and I wish to have my spouse/domestic partner as
the subscriber.
™
I am ending my coverage on a family plan and wish to continue on my
own on an individual plan.
™
I wish to switch the subscriber and spouse/domestic partner roles on our
current plan.
™
Iwish to combine accounts. (Please pick your plan on page 3.)
™
I am ending my coverage but wish to keep my child(ren) on the plan.
60395110 California 2016
™
I am ending my and my spouse’s/domestic partner’s coverage but
wish to keep our child(ren) on the plan.
™
I wish to change plans. (Please select your plan on page 3.)
™
I wish to add medical coverage for a family member.
™
I wish to end medical coverage for a family member.
™
I wish to add optional adult dental coverage (for members 19 and
older). (Please select your option on page 3.)
I wish to end optional adult dental coverage.
™
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D. Which Family Members Are Affected by the Change? (Please list below.)
Spouse/domestic partner
First name
Sex
™ Male
™ Add medical coverage
™ End medical coverage
Middle name
™ Add optional adult dental coverage
™ End optional adult dental coverage
Last name
Medical record number (if any)
Date of birth (mm/dd/yyyy)
™ Add medical coverage
™ End medical coverage
Middle name
™ Add optional adult dental coverage
™ End optional adult dental coverage
Last name
Social Security number
Medical record number (if any)
Date of birth (mm/dd/yyyy)
™ Female
Dependent 3
First name
™ Add medical coverage
™ End medical coverage
Middle name
™ Add optional adult dental coverage
™ End optional adult dental coverage
Last name
Social Security number
Medical record number (if any)
Date of birth (mm/dd/yyyy)
™ Female
Dependent 4
First name
™ Add medical coverage
™ End medical coverage
Middle name
™ Add optional adult dental coverage
™ End optional adult dental coverage
Last name
Social Security number
Medical record number (if any)
Date of birth (mm/dd/yyyy)
™ Female
Dependent 5
First name
Sex
™ Male
Date of birth (mm/dd/yyyy)
Social Security number
First name
Sex
™ Male
Medical record number (if any)
™ Female
Dependent 2
Sex
™ Male
Last name
Social Security number
First name
Sex
™ Male
Middle name
™ Add optional adult dental coverage
™ End optional adult dental coverage
™ Female
Dependent 1
Sex
™ Male
™ Add medical coverage
™ End medical coverage
™ Add medical coverage
™ End medical coverage
Middle name
™ Add optional adult dental coverage
™ End optional adult dental coverage
Last name
Social Security number
Date of birth (mm/dd/yyyy)
™ Female
60395110 California 2016
Medical record number (if any)
2
Option 1: Choose Your Health Plan
If you indicated that you would like to change plans or add medical
coverage for a family member, please select the plan you would like.
Each family member you listed on page 2 will be moved into the
plan you select. If you wish to enroll family members in different
plans, please submit a separate form for each plan.
™ KP — Bronze 60 HSA HMO 5500/40%
™ KP — Gold 80 HMO Copay
™ KP — Bronze 60 HMO
™
KP — Gold 80 HMO
™ KP — Bronze 60 HSA HMO
™ KP — Silver 70 HMO
™ KP — Silver 70 HMO 1500/40
Coinsurance
™ KP — Platinum 90 HMO
™ KP — Minimum Coverage
™ KP — Silver 70 HSA HMO 2700/15%
Option 2: Choose Your Optional Dental Plan
You can enroll in or end adult dental coverage in the optional Dental Insurance Plan during open enrollment, annual member renewal, or a special
enrollment period. Optional adult dental coverage is available for an additional monthly charge. Our optional adult dental coverage is underwritten by
Kaiser Permanente Insurance Company (KPIC), a subsidiary of Kaiser Foundation Health Plan, Inc., and administered by Delta Dental of California, one of
the nation’s largest and most experienced dental benefits providers.
™ Add optional adult dental coverage.
™ End optional adult dental coverage.
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Sign the Kaiser Foundation Health Plan Arbitration Agreement
I understand that (except for Small Claims Court cases, claims subject to a Medicare appeals procedure or the
ERISA claims procedure regulation, and any other 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), 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, 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 Membership Agreement,
Disclosure Form, and Evidence of Coverage.
Subscriber or parent or legal guardian for a member under age 18
Date (mm/dd/yyyy)
X
Spouse/domestic partner
Date (mm/dd/yyyy)
X
Date (mm/dd/yyyy)
Dependent (18 or older)
X
Dependent (18 or older)
Date (mm/dd/yyyy)
X
Dependent (18 or older)
Date (mm/dd/yyyy)
X
Dependent (18 or older)
Date (mm/dd/yyyy)
X
Sign the Form
I understand that if I knowingly provide false, incomplete, or misleading information on this Account Change Form for the purpose of obtaining coverage,
my coverage may be rescinded, meaning that my contract will be declared null and void as if it had never occurred.
For all account and plan changes, the subscriber and any new dependents 18 or older must sign.
Subscriber/new subscriber (parent or legal guardian for a member under 18)
Date
X
Spouse/domestic partner (18 or older)
Date
X
Dependent (18 or older)
Date
X
Dependent (18 or older)
Date
X
Dependent (18 or older)
Date
X
Contact Information
Mail to: Kaiser Permanente
P.O. Box 23127
San Diego, CA 92193-9921
60395110 California 2016
Or fax to: Membership Administration
1-858-614-3344
Questions? Call 1-800-464-4000 (TTY 711).
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