Form Va-Lg-Kfhp-En-Chg - Kaiser Permanente Enrollment & Change Form Hmo Plan Offerings Page 3
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7Kaiser 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
If you have any questions concerning the benefits and services that are provided by or excluded under your plan offering, please contact a
Member Services representative at (800) 777-7902 TTY Services: (301)-879-6380 before signing this form.
Please see instructions located at the back of this booklet for directions on how to complete this form. After you have completed this form, please
sign and return all pages, including the instructions, to your employer’s benefits office. DO NOT SEND THIS FORM TO KAISER PERMANENTE
UNLESS OTHERWISE INSTRUCTED.
If you are enrolling in our Medicare product, there is a separate enrollment process. Please call a Member Services representative at (800) 777-7902 TTY
Services: (301)-879-6380 for more information.
TO BE COMPLETED BY EMPLOYER Please print or type in black ink only.
ENROLLMENT TYPE
EMPLOYMENT STATUS
GROUP NO.
SUBGROUP NO.
NEW
CHANGE
Active
Retired
THE INFORMATION BELOW IS REQUIRED BY LAW. FAILURE TO COMPLETE WILL RESULT IN A DELAY OF APPLICATION PROCESSING.
CHECK IF NEW HIRE
IF NEW HIRE, INDICATE NEW HIRE DATE (MM/DD/YYYY)
EMPLOYEE LAST NAME
FIRST NAME
MI
SUFFIX
Check One and indicate date of event:
New enrollment
New enrollment Effective Date (MM/DD/YYYY)
Open enrollment (complete sections A, C, F, G)
Open enrollment Effective Date (MM/DD/YYYY)
COBRA (complete sections A, B, E, G)
COBRA Effective Date (MM/DD/YYYY)
Loss of other coverage (complete sections A, C, F, G)
Cancel all coverage (empl. and family) (complete sections A, G) Effective Date of Cancellation (MM/DD/YYYY)
EMPLOYER AUTHORIZED REPRESENTATIVE SIGNATURE
I hereby certify that this(these) enrollment(s) has been reviewed and meet(s) all eligibility requirements
Printed or Typed Name/Title
Employer Signature
Date
Telephone
Fax
*Additional documentation will be required.
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May require additional information
VA-LG-KFHP-EN-CHG(01-12)
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