Kaiser Permanente Enrollment Change Form printable pdf download

Kaiser Permanente Enrollment Change Form

Instructions

When to use this form

Use this form to add or remove a dependent if you currently have Kaiser

Permanente Self and Family coverage and adding or removing a dependent will

not change your type of enrollment, FEHB plan, or option. You may also use this

form to change the name of a dependent. Submit the enrollment change form

and supporting documents directly to Kaiser Permanente.

Do not use this form if you need to enroll, change the type of enrollment (Self

Only and Self and Family), change health plans or options or cancel your FEHB

enrollment. Instead, follow instructions to enroll in a health plan for either

employees or annuitants on opm.gov.

How to complete and submit this form

Complete the following sections:

A. ENROLLMENT/CHANGE REASON

B. EMPLOYEE

C. FAMILY

D. Employee/Applicant signature and date

Your agency does not need to complete the section titled “TO BE COMPLETED

BY EMPLOYER”

Mail or fax the completed form and any supporting documentation (such as a

birth certificate, marriage certificate or divorcee decree) to:

Mail

Kaiser Permanente Federal Accounts

P.O. Box 23758

San Diego, CA 92193-3758

Fax

Northern California Federal Team: 858-614-3344

Southern California Federal Team: 858-614-3345

Kaiser Permanente Enrollment Change Form