Kaiser Permanente Colorado Student Dependent Form

Dependent Certification Form
NOTE: Please refer to your Evidence of Coverage for your plan’s definition of a dependent.
Please print, complete and sign the form below. Use one form for each eligible dependent.
Subscriber Name: _________________________________________________________________
Subscriber Health Record Number: ___________________________________________________
Subscriber Address: _________________________________________________________________
City: ________________________________State: ________________________Zip code: ___________
Dependent Name: ___________________________________________________________
Dependent Health Record Number: __________________________________________
Dependent date of birth: (MM/DD/YY): ___________________________________________
Check and complete the applicable category:
Dependent non-student (complete below):
Check here if dependent lives at subscriber’s address listed above.
OR
Dependent Address: _____________________________________________________________
City: ______________________________ State: ______________ Zip Code: ________________
Dependent student (Must be enrolled at least 12 credit hours per semester) (complete below):
School Name: ________________________________________________________________
School Address: _______________________________________________________________
City: _______________________________State: _______________ Zip Code: _______________
By signing below, I certify that the information above is correct.
___________________________________________________________________________________
Subscriber signature
Date
Once completed and signed, please mail, fax or e-mail form(s) to:
Kaiser Permanente Membership Administration
2530 S Parker Road, Suite 350, Aurora, CO 80014
Fax Number: 303-306-2626
E-mail: [email protected]
To be completed by Kaiser Permanente:
Date reviewed:_____________________ Date updated________________________________
Group/Subgroup#__________________________________ Out-of-Area benefit: Yes
No
Dependent Code used:____________________ Effective date :_____________________________
Northern CO Dep. student
Southern CO Dep. student
Out-of-Area Dep. student
Cross Market Member
Visiting Member: Yes
No:
State: _____________________
Date Confirmation Letter Mailed: ________________
Completed by: ______________________________________________________________
updated: 1/20/2016