Kaiser Permanente Enrollment Change Form Page 2
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3California 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.
Social Security No.
Add
Delete
Child
Student
Gender
M
F
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)
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