Form Va-Lg-Kfhp-En-Chg - Kaiser Permanente Enrollment & Change Form Hmo Plan Offerings Page 2
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7Section G: Subscriber Sign-off
Section F: Other Coverage Information
Review and sign this form. Before you sign this form,
Tell us if you, your spouse, or other family dependents
please make certain you have read all coverage materials
are covered by other group health insurance plans. This
and have selected a primary care provider. Failure to
may occur when both spouses are employed and have
complete all relevant parts of this form may delay or
health care benefits from one or more health plan(s).
prevent enrollment and the issuance of a member ID
If you or your family are covered by more than one health
card.
plan, you may be able to save money while improving
your coverage. If you are covered by two plans that
MISREPRESENTATION
include a Coordination of Benefit (COB) provision, you
If you knowingly or intentionally file an enrollment form or
may be able to eliminate some of your out-of-pocket
statement of claim containing any materially false or
expenses for approved services now only partially
deceptive statements, or you knowingly or intentionally
covered by those plans.
fail to provide requested information, you may have
If the Coordination of Benefits provisions apply to you,
violated state law which could subject you to civil and/or
your signature on this form will permit KFHP-MAS to bill
criminal penalties. You may also be liable to KFHP-
any other health care policy that is determined to be the
MAS for the cost of health care services provided
primary carrier in accordance with the National
because of the false or misleading information or
Association of Insurance Commissioners (NAIC)
omission.
guidelines including , but not limited to; Medicare, Motor
Vehicle Insurance (Except Virginia residents and Virginia
group employees. Virginia residents and Virginia group
employees are not subject to subrogation of a recovery
for personal injuries from a third person.), Workers’
Compensation, Tricare, Veterans Administration, so long
as you are enrolled in the primary plan and such plan
remains primary to KFHP – MAS plan. Your signature
authorizes KFHP-MAS and its employees to release any
records or information with respect to any claim for
covered services that may be requested by your other
carrier. Such authorization shall be valid for the duration
of coverage. For more information on Coordination of
Benefits, please call a Member Services representative at
.
(800) 777-7902 TTY Services: (301)-879-6380
REMOVE THIS INSTRUCTION SHEET PRIOR TO SUBMITTING FORM
*Additional documentation will be required.
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May require additional information
VA-LG-KFHP-EN-CHG(01-12)
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