Disabled Dependent Enrollment Application Form PDF Details

Navigating the process of securing health care coverage for a disabled dependent requires precise attention to detail and a thorough understanding of the application procedure. The Disabled Dependent Enrollment Application form serves as a critical step for subscribers of the Kaiser Foundation Health Plan, Inc. (KFHP), who are seeking to enroll or recertify a dependent with a disability for health care coverage. This comprehensive form is split into two main parts: Part A, which must be filled out by the subscriber providing detailed information about the applicant and the subscriber themselves, and Part B, which is to be completed by the applicant's physician, detailing the nature, severity, and prognosis of the disability. Alongside these sections, the form requires various pieces of documentation to support the application, all of which should reflect the 12-month period prior to submission. Once completed, this document, inclusive of all necessary attachments, should be mailed or faxed to the specified Kaiser Foundation Health Plan, Inc. address or fax number. This initial step, if accurately followed, paves the way towards securing the much-needed disabled dependent coverage, ultimately taking effect the first of the month following the determination date. Also, for those seeking to appoint an authorized representative in the enrollment process, the form accommodates this need, ensuring that all avenues for support and assistance are clearly outlined and accessible.

QuestionAnswer
Form NameDisabled Dependent Enrollment Application Form
Form Length5 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 15 sec
Other namespermanente disabled dependent enrollment, kaiser permanenete incapacitated dependent application, kaiser form 5549 0627 01, kaiser dependent application

Form Preview Example

Member Services Department, return to:

Kaiser Foundation Health Plan, Inc. P.O. Box 23219

San Diego, CA 92193-3219 Or fax to: (858) 614-3344

Disabled฀Dependent฀ Enrollment฀Application

To the Subscriber: Please provide the following information about the applicant for whom you are seeking enrollment or recertification by Kaiser Foundation Health Plan, Inc. (KFHP), for disabled dependent health care coverage. Please complete all of Part A (Sections 1–4). Your physician must complete Part B. Once all sections of the application have been completed with all supporting documentation attached (all supporting documentation must be reflective of the 12-month period prior to the date of this application), mail or fax the application to the address/fax number at the top of the page. If the applicant qualifies, disabled dependent coverage will be made effective the first of the month following the date of our determination.

Part฀A

Section I–Applicant Information

Applicant’s last name (please print)

First name

MI

Medical record number

 

 

 

 

 

Address

 

Telephone number

 

 

 

 

 

 

 

City

State

ZIP

 

 

 

 

 

 

Applicant’s Social Security number

Applicant’s birthdate (MM/DD/YYYY)

Applicant’s relationship to KFHP

 

 

subscriber/subscriber’s spouse

 

 

 

 

 

Section II–Subscriber Information

 

 

 

 

 

 

 

 

 

Subscriber’s last name (please print)

First name

MI

Medical record number

 

 

 

 

 

Address

 

Telephone number

 

 

 

 

 

 

 

City

State

ZIP

 

 

 

 

 

 

Social Security number

Group number

Family account number

 

 

 

 

Subscriber’s employer

Employer address

Employer telephone number

 

 

 

 

 

Section III–Physician Information

 

 

 

 

 

 

 

 

Physician’s name

KFHP facility or physician location/address

 

Office telephone number

 

 

 

 

 

5549-0627-01-r03 Revised November 2004

Member Services Department, return to:

Kaiser Foundation Health Plan, Inc. P.O. Box 23219

San Diego, CA 92193-3219 Or fax to: (858) 614-3344

Disabled฀Dependent฀ Enrollment฀Application

Part฀A฀(continued)

Section IV–Subscriber Questionnaire

Circle One

Please read each of the following statements carefully. Indicate a “Yes” or “No” response to the statements below. You

 

 

 

must provide all information requested in order for your application to be processed. If you need more space, attach a

 

 

 

separate sheet of paper.

 

 

 

 

 

 

 

 

 

 

 

1. Is the applicant currently enrolled as a dependent on your account? If “No,” has the applicant been enrolled as a

 

 

 

dependent on your KFHP plan within the past 12 months prior to the date of this application? Please explain:

 

 

 

____________________________________________________________________________________________________________

Yes

 

No

 

 

 

 

 

 

____________________________________________________________________________________________________________

 

 

 

____________________________________________________________________________________________________________

 

 

 

 

 

 

 

 

 

2. Is the applicant dependent upon you or your spouse for his or her support and maintenance? (Support and maintenance

 

 

 

of the applicant is defined as customary living expenses such as housing, transportation, food, medical care, clothing,

 

 

 

etc., that you or your spouse provides.) If yes, you must complete the following for the dependent’s average

 

 

 

monthly living expenses reflective of the past 12 months prior to the date of this application.

 

 

 

 

 

 

 

 

 

Dependent average

Expense Type

*Other expense type explanation

 

 

 

monthly expense

 

 

 

 

 

 

 

 

 

 

 

$

Housing/Rent

 

Yes

 

No

 

 

 

 

$

Transportation

 

 

 

 

 

 

 

 

 

 

$

Food/Toiletries

 

 

 

 

 

 

 

 

 

 

$

Medical Care

 

 

 

 

 

 

 

 

 

 

$

Clothing

 

 

 

 

 

 

 

 

 

 

$

*Other

 

 

 

 

 

 

 

 

 

 

$

*Other

 

 

 

 

 

 

Total Monthly

$

 

 

 

Expenses

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. Was the applicant claimed as a dependent on your or your spouse’s most recent federal tax return? If yes, please

 

 

 

provide a copy of the page of your most recent tax return that lists your dependent(s). If no, please explain why:

 

 

 

____________________________________________________________________________________________________________

Yes

 

No

____________________________________________________________________________________________________________

 

 

 

 

 

 

____________________________________________________________________________________________________________

 

 

 

 

 

 

 

 

4. Does the applicant qualify or receive any government-sponsored aid or income because of his or her disabled status?

 

 

 

If yes, please check all that apply:

 

 

 

 

 

 

 

 

 

 

 

Type of Aid

Amount of Benefit

Benefit Start Date

 

 

 

 

 

 

 

 

 

❑ Social Security Disability Insurance (SSDI)?

 

 

Yes

 

No

 

 

 

 

❑ Supplemental Security Income (SSI)?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

❑ Medi-Cal?

N/A

N/A

 

 

 

 

 

 

 

 

 

❑ Medicare Part A (Hospital)

N/A

N/A

 

 

 

 

 

 

 

 

 

❑ Medicare Part B (Medical Care)

N/A

N/A

 

 

 

❑ Other (Describe):

 

 

 

 

 

 

 

 

5549-0627-01-r03 Revised November 2004

Member Services Department, return to:

Kaiser Foundation Health Plan, Inc. P.O. Box 23219

San Diego, CA 92193-3219 Or fax to: (858) 614-3344

Disabled฀Dependent฀ Enrollment฀Application

Part฀A฀(continued)

Section IV–Subscriber Questionnaire (continued)

Circle One

Please read each of the following statements carefully. Indicate a “Yes” or “No” response to the statements below. You

 

 

must provide all information requested in order for your application to be processed. If you need more space, attach a

 

 

separate sheet of paper.

 

 

 

 

 

5. Has the applicant worked, including sheltered work, within the past 12 months prior to the end date of the application?

 

 

If yes, please attach proof of the applicant’s earnings for the past 12 months from the date of this application and

 

 

provide the following information:

 

 

Name and address of employer:

 

 

____________________________________________________________________________________________________________

 

 

____________________________________________________________________________________________________________

Yes

No

____________________________________________________________________________________________________________

 

 

 

 

Supervisor’s name and telephone number:

 

 

____________________________________________________________________________________________________________

 

 

____________________________________________________________________________________________________________

 

 

____________________________________________________________________________________________________________

6.Is the applicant currently living with you? If yes, how long? ___________________________

If no, please indicate the address where the applicant is residing:

____________________________________________________________________________________________________________

Yes

No

 

____________________________________________________________________________________________________________

 

 

 

7. Has the applicant lived in a group home or other assisted living arrangement within the past 12 months prior to the

 

date of the application? If yes, please provide the following information:

 

Name: _____________________________________________________________________________________________________

Yes

No

 

Address: ___________________________________________________________________________________________________

 

Phone number: _____________________________________________________________________________________________

8.Has the applicant attended school within the past 12 months prior to the date of application? If yes, specify the name of the school and the course of study:

Yes

No

____________________________________________________________________________________________________________

 

 

 

 

____________________________________________________________________________________________________________

I hereby certify that, to the best of my knowledge, the above information is complete and correct.

Subscriber’s signature

X

Date:

5549-0627-01-r03 Revised November 2004

Member Services Department, return to:

Kaiser Foundation Health Plan, Inc. P.O. Box 23219

San Diego, CA 92193-3219 Or fax to: (858) 614-3344

Disabled฀Dependent฀ Enrollment฀Application

Part฀B

Section I–To be completed by applicant’s physician: The following information is needed for use in connection with an application for continued health insurance coverage for a disabled dependent. Please provide your full reply and describe the nature and severity of the impairment. If Part A has been completed in full and all supporting documentation is included, you may mail or fax this application to the address and fax number at the top of the page.

NOTICE TO PHYSICIAN: PLEASE TYPE OR PRINT.

Applicant’s last name, first name

Medical record number

Subscriber’s last name, first name

Medical record number

CLINICAL DESCRIPTION OF APPLICANT’S CONDITION, INCLUDING DIAGNOSIS AND PROGNOSIS CAUSING DISABILITY AND DESCRIPTION OF LIMITATIONS: (Must be completed by physician)

(To add more comments, please attach additional documentation.)

PHYSICIAN COMMENTS: (Must be completed by physician)

(To add more comments, please attach additional documentation.)

IN ADDITION TO THE INFORMATION REQUIRED ABOVE, PLEASE PROVIDE ANSWERS TO THE FOLLOWING QUESTIONS:

1)Date disability occurred

2)In your medical opinion, is the disability:

Mental retardation ❑ Yes ❑ No Physical handicap ❑ Yes ❑ No

Biologically based psychiatric disorder ❑ Yes ❑ No

3) In your medical opinion, is the disability likely to improve? ❑ Yes ❑ No

4) In your medical opinion (choose one):

฀ ❑ Yes, the applicant is capable of self-sustaining employment

฀ ❑ No, the applicant is not capable of self-sustaining employment

Attending physician’s signature

Date

Physician’s printed name

KFHP facility or physician’s mailing address

City

ZIP

Physician’s office telephone number

5549-0627-01-r03 Revised November 2004

Member Services Department, return to:

Kaiser Foundation Health Plan, Inc. P.O. Box 23219

San Diego, CA 92193-3219 Or fax to: (858) 614-3344

Disabled฀Dependent฀ Enrollment฀Application

Statement฀of฀Authorized฀Representative

Part฀A:฀If you wish to give authority to another party to file an appeal on your behalf for enrollment on your parents’ plan as a disabled dependent, please complete the following information. If you wish this person to receive Protected Health Information (PHI) regarding your medical history and care, you must check the appropriate box(es) below and you and your representative must both sign and date this form. Please return the completed form to Kaiser Foundation Health Plan California Service Center - Disabled

Dependent Coordinator - P.O. Box 23219 - San Diego, CA 92193-3219 or fax to: (858) 614-3344.

Your name and address:

Daytime phone number

Medical record number

Alternate phone number

Medicare number

Part฀B:฀I hereby authorize the person named below to represent me for my eligibility as a disabled dependent with Kaiser Permanente based on both my medical and financial status.

I understand that this authorization is voluntary and, if I choose to do so, I have the right to revoke it in writing to KFHP and to my designated representative. KFHP and my designated representative will no longer use or disclose my PHI, except to the extent KFHP or my designated representative has taken action in reliance upon this authorization.

Name of designated person

Address

City

State

ZIP

Daytime phone number

Evening phone number

❑I authorize KFHP to disclose Protected Health Information regarding my medical condition and care and/or payment information to the above named individual. This information must be relevant to the request filed with Member Services on _________________

(date of request).

The above authorization may include the following medical records and type of information, if box(es) are checked:

❑ Psychiatric treatment

❑ Drug/alcohol or other chemical dependency treatment

❑HIV-related treatment or testing

❑This authorization shall become effective immediately and shall remain in effect until the earlier or final resolution of my request or

________________ (specify date).

Your Signature __________________________________________________________________ Date_______________________________

Part฀C:฀I am authorized to sign this authorization on behalf of _____________________________________________ and on the basis of:

❑ Legal authority (Power of Attorney, etc.)

❑ Written designation by the Member

❑Parent, guardian, or other individual acting in loco parentis

Authorized representative _________________________________________________________ Date_______________________________

5549-0627-01-r03 Revised November 2004

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kaiser disabled dependent conclusion process shown (step 1)

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Office telephone number, KFHP facility or physician, and r Revised November of kaiser disabled dependent

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The best ways to fill out kaiser disabled dependent portion 3

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