Kaiser Enrollment Form PDF Details

Navigating the Kaiser Enrollment Form is a critical step for employees and employers alike within the California Region, ensuring access to healthcare benefits tailored to their needs. This comprehensive document, designed for the exclusive use of group enrollment or modifications, demands attention to detail, requiring black ink for entries and urging careful review of instructions. It necessitates employer input for foundational information such as company name, hire and effective dates, alongside the employee’s responsibility to specify enrollment or changes, including personal and dependent information. This form covers a broad spectrum of potential changes, from new hires and open enrollment periods to personal events like marriage or the loss of other coverage. Additionally, it addresses specific needs such as the inclusion of dependents, capturing their essential information and any changes in student status or residence that may affect their eligibility. At its core, the Kaiser Enrollment Form binds the signer to Kaiser Permanente's arbitration agreement, waiving the right to resolve disputes through traditional court processes in favor of binding arbitration, a clause with specified exclusions. This document emphasizes not just the procedural aspect of enrolling in healthcare plans but also enshrines the importance of accuracy and clarity in communicating vital information to ensure seamless coverage and understanding of the legal implications embedded in the enrollment process.

QuestionAnswer
Form NameKaiser Enrollment Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameskaiser form online, kaiser permanente account change form california, kaiser form pdf, how to kaiser form

Form Preview Example

California Region Group Enrollment/Change Form

Please print or type in black ink only. See instructions on reverse before completing this form. Make a copy for your records.

TO BE COMPLETED BY EMPLOYER

Company name

 

Hire date (mm/dd/yyyy)

 

 

Effective enrollment/

Group number

Enrollment unit

change date (mm/dd/yyyy)

A. ENROLLMENT/CHANGE REASON (see Change Table for assistance)

 

 

 

New group:

Yes No

 

 

 

 

 

New Hire (complete sections A, B, C, D)

 

 

 

 

 

 

Open Enrollment (complete sections A, B, C, D)

 

 

 

 

 

Health Plan (Check one)

HMO Plan

Deductible Plan

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Loss of Other Coverage (complete sections A, B, C, D)

 

Other (please specify)

 

 

 

 

 

 

 

 

 

Name Change (complete sections A, B, C, D) From:

 

 

 

 

 

 

 

 

 

To:

 

 

 

 

 

 

 

 

 

Event Date (mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B. EMPLOYEE Have you ever been a Kaiser Permanente member?

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical Record No. (if known)

 

 

 

 

 

 

 

 

Social Security No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Gender

 

M

F

 

Name (Last, First, MI)

 

 

 

 

 

 

 

 

 

 

Birth Date (mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home Address

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

 

 

State

 

ZIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Work Phone

 

 

 

 

 

 

Home Phone

 

 

 

 

Email

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ethnicity

 

 

 

 

 

 

 

Preferred Language

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C. FAMILY For additional dependents, attach a separate sheet with employee’s name at top. (Last, First, MI)

 

 

 

 

 

Add

Delete

Spouse

Domestic partner

 

Gender

M

F

 

 

Social Security No.

 

 

 

 

 

Spouse/domestic partner name:

 

 

 

 

 

 

 

 

 

 

 

Birth Date (mm/dd/yyyy)

 

 

 

 

 

Former last name (if any):

 

 

 

 

 

 

 

 

 

 

 

 

Medical Record No.

 

 

 

 

 

Add

Delete

Child

Student

 

 

 

 

Gender

M

F

 

 

Social Security No.

 

 

 

 

 

Dependent name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Birth Date (mm/dd/yyyy)

 

 

 

 

 

Relationship:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical Record No.

 

 

 

 

 

Add

Delete

Child

Student

 

 

 

 

Gender

M

F

 

 

Social Security No.

 

 

 

 

 

Dependent name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Birth Date (mm/dd/yyyy)

 

 

 

 

 

Relationship:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical Record No.

 

 

 

 

 

Add

Delete

Child

Student

 

 

 

 

Gender

M

F

 

 

Social Security No.

 

 

 

 

 

Dependent name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Birth Date (mm/dd/yyyy)

 

 

 

 

 

Relationship:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical Record No.

 

 

 

 

 

Do any of dependents above live at another address?

 

Yes

No If yes, complete the following:

 

 

 

 

 

 

 

 

 

Name (Last, First, MI):

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D. Kaiser Foundation Health Plan, Inc., and Kaiser Permanente Insurance Company Arbitration Agreement*

I understand that (except for Small Claims Court cases, claims subject to a Medicare appeals procedure, and, if I am enrolled in coverage that is subject to the ERISA claims procedure regulation (29 CFR 2560.503-1), certain benefit-related disputes*) any dispute between myself, my heirs, relatives, or other associated parties on the one hand and Kaiser Foundation Health Plan, Inc. (KFHP), Kaiser Permanente Insurance Company (KPIC), 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 or coverage by KPIC, 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 Evidence of Coverage and in the Certificate of Insurance.

*Disputes arising from any of the following KPIC products are not subject to binding arbitration: 1) Tiers 2 & 3 of the Point of Service (POS) Plans; 2) the Preferred Provider Organization (PPO) and Out of Area Indemnity (OOA) Plans; and 3) the KPIC Dental plans.

Signature Required for all Kaiser Permanente Plans

Date

(Excluding KPIC PPO, KPIC OOA, and KPIC Dental Plans)

 

California Region Group Enrollment/Change Form

General instructions

1.Please print firmly and legibly in black ink.

2.To enroll, the subscriber must reside or work within one of the ZIP codes listed on the enclosed sheet.

3.The employer must complete the first section titled “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 and B. 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 employer section), the subscriber should make a copy for his or her records, and 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 information.

Section A: The subscriber must complete this section.

Section B: The subscriber must always complete this section. Use the Change Table (below) for assistance.

Section C: The subscriber must indicate the requested change to the 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 be marked only if the dependent qualifies as an “overage dependent” attending school. Please contact your employer regarding rules for overage dependent students. A completed STUDENT CERTIfiCATION form may be required.

Section D: The subscriber must sign and date this section.

Change Table

Add dependent

Event date

 

 

Acquired student status*

Student status date

 

 

Family adoption*

Adoption date

 

 

Loss of coverage

Coverage loss date

 

 

New spouse (marriage)

Marriage date

 

 

Moved into service area

Move date

 

 

Newborn addition

Birth date

 

 

Open enrollment

Open enrollment effective date

 

 

Delete dependent

Event date

 

 

Loss of student status

Status change date

 

 

Divorce

Divorce date

 

 

Member deceased*

Death date

 

 

Delete dependent(s)

Dependent termination date

 

 

Open enrollment

Open enrollment effective date

 

 

Demographic Change

Event date

 

 

Address change, telephone number change

Status change date

 

 

Demographic (name, birthdate, social security number) change

Status change date

*Additional documentation may be required.

79829

Revision date 10/2011

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When it comes to blanks of this specific document, here is what you should consider:

1. To start with, once completing the kaiser group enrollment form, start in the area that has the next blanks:

Filling out part 1 of kaiser form online

2. Just after the prior part is filled out, go on to type in the relevant details in all these: C FAMILY For additional dependents, Add, Delete, Spouse, Domestic partner, Gender, Spousedomestic partner name Former, Add, Delete, Child, Student, Gender, Dependent name Relationship, Add, and Delete.

Domestic partner, Child, and Delete inside kaiser form online

It's easy to make a mistake when filling in your Domestic partner, for that reason be sure to reread it before you decide to submit it.

3. This third step is hassle-free - fill out all the empty fields in Dependent name Relationship Do any, Signature Required for all Kaiser, and Date to complete this process.

Completing part 3 in kaiser form online

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