Form Va-Lg-Kfhp-En-Chg - Kaiser Permanente Enrollment & Change Form Hmo Plan Offerings
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7VIRGINIA
Kaiser Foundation Health Plan of the
Mid-Atlantic States, Inc. (KFHP-MAS)
2101 East Jefferson Street, Rockville, Maryland 20852
KAISER PERMANENTE ENROLLMENT & CHANGE FORM
HMO PLAN OFFERINGS
INSTRUCTIONS
Welcome to Kaiser Foundation Health Plan of the Mid-
Section B: Waiver of Coverage
Atlantic States, Inc. (KFHP-MAS). We look forward to
Complete this section if you voluntarily elect to waive all
receiving your Enrollment and Change form. If you have
insurance coverage offered by your employer. You will
any question concerning the benefits and services
also need to read and sign section G.
that are provided by or excluded under these plan
offerings, please contact a Member Services
If Making a Change Section
representative at
(800) 777-7902 TTY Services:
Complete this section if you are making a change (add or
before signing this form.
(301)-879-6380
delete) to dependent status. If you are adding a
dependent please complete sections A, C, F and G.
After you have completed this form, please sign and
return it to your employer’s benefits office. DO NOT
Section C: Family Information
SEND THIS FORM TO KAISER PERMANENTE
Make sure your dependents meet your group’s eligibility
UNLESS OTHERWISE INSTRUCTED.
guidelines. If you have any questions, contact your
employer’s benefits office. If you know the Medical record
If you are enrolling in Medicare, there is a separate
number, please provide it in the requested space. To
enrollment process. Please call a Member Services
select a primary care provider, please review the KFHP-
representative at
(800) 777-7902 TTY Services: (301)-
MAS Provider Directory and enter the provider code of
for more information.
879-6380
the primary care provider for you and each member of
your family. The primary care provider must be listed in
How to Complete this form – Please Print
the KFHP-MAS portion of the Provider Directory. To
Use this form to enroll, waive or change (add or delete)
obtain a directory please call a Member Services
your family members’ membership status. To be a
representative at
(800) 777-7902 TTY Services: (301)-
Subscriber, you must live or work within our service area
, or see our website at
879-6380
and you must be an employee who meets all of your
employer’s eligibility guidelines. If you are electing to
Section D: Maximum Age/Disabled Dependent
waive coverage, you only need to complete Sections
Please complete this section to list any dependents that
A, B and sign in section G. If you have any questions,
exceed your employer’s’ maximum limiting age
contact your employer’s benefits office.
requirements or are disabled. You will be requested to
provide additional information to document dependents
To Be Completed by Employer
that are indicated in this section.
Your employer will complete this section.
Section E: Dependents residing at another
Section A: Employee Information
PERMANENT address
Please provide information about yourself. To indicate
Please use this section to document any dependents that
your choice of primary care provider, please see the line
have another permanent address other than that of the
at the end of the section.
Subscriber. You will be requested to provide additional
information to document dependents that are indicated in
this section. This section does not apply to dependents
who are full time students living in temporary housing
while attending their classes.
VA-LG-KFHP-EN-CHG(01-12)
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