Kaiser Permanente Enrollment Change Form Page 3
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3California Region Group Enrollment/Change Form
General instructions
Instructions for completing employer and new
enrollment sections and sections A through D:
1. Please print firmly and legibly in black ink.
To be completed by employer: The employer must
2. To enroll, the subscriber must reside or work within
complete all fields to ensure we have correct account
one of the ZIP codes listed on the enclosed sheet.
and enrollment information.
3. The employer must complete the first section titled
Section A: The subscriber must complete this section.
“To be completed by employer.”
Section B: The subscriber must always complete this section.
4. The employer is responsible for confirming all information
Use the Change Table (below) for assistance.
prior to submitting, especially effective dates, as these affect
Section C: The subscriber must indicate the requested change
your Health Plan dues.
to the account and complete all fields for any dependents
5. The employee/subscriber must complete Sections A and B.
being enrolled. We will verify the eligibility of these dependents
See right column for detailed instructions.
during the enrollment process. Be sure to include any former
last names for both spouses and dependents. Also indicate
6. Be sure to sign and date the bottom of the form.
the appropriate role. The student role should be marked only if
7. Once the form is complete (including employer section),
the dependent qualifies as an “overage dependent” attending
the subscriber should make a copy for his or her records,
school. Please contact your employer regarding rules for overage
and to use as a temporary ID card, after the effective date.
dependent students. A completed Student Certification form
8. All changes to accounts, including effective dates and child or
may be required.
student status, will be made in accordance with the contractual
Section D: The subscriber must sign and date this section.
agreement between the purchaser and Kaiser Permanente.
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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