Form Va-Lg-Kfhp-En-Chg - Kaiser Permanente Enrollment & Change Form Hmo Plan Offerings Page 5
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7VIRGINIA
B. Waiver of Coverage
By completing this section, I acknowledge that I was given
Reason for refusal: (Please check all appropriate boxes)
the opportunity to enroll in this plan of group health benefits
other group coverage sponsored by my employer*
offered by my employer. I refuse the following:
other group coverage sponsored by my Spouse’s employer*
All Coverage
Coverage for my Spouse
other group coverage sponsored by another organization*
Coverage for my Children
other reasons (please explain)
I understand that if I or my Dependents later wish to enroll
____________________________________________________
for any of the coverage(s) refused, I/they will be required
____________________________________________________
to submit documentation to support enrollment outside the
____________________________________________________
Open Enrollment period and coverage may be subject to late
____________________________________________________
enrollment provisions, as allowed by law and as directed by my
____________________________________________________
employer.
IF MAKING A CHANGE, COMPLETE THE FOLLOWING:
ADD DEPENDENTS (Complete sections A, C, F, G)
Date of Event (MM/DD/YYYY)
Date of Event (MM/DD/YYYY)
Birth
Loss of other Coverage*
Adoption*
Marriage*
Address (complete sections A, G)
Telephone (complete sections A, G)
Name Change*________________________________________
Other (please specify; Complete sections A, C, G)*
Previous Name________________________________________
C. FAMILY INFORMATION (If additional space is needed please use another form and attach it to this form)
ADD
DELETE
SPOUSE
DOMESTIC PARTNER
(If eligible under your plan)
LAST NAME
FIRST NAME
MI
SUFFIX
SOCIAL SECURITY NUMBER
MEDICAL RECORD NO.
DATE OF BIRTH (MM/DD/YYYY)
MALE
FEMALE
Primary Care Provider (PCP) Name _____________________________________________________________________________ PCP ID #
ADD
DELETE
CHILD
OTHER ____________________________
LAST NAME
FIRST NAME
MI
SUFFIX
SOCIAL SECURITY NUMBER
MEDICAL RECORD NO.
DATE OF BIRTH (MM/DD/YYYY)
MALE
FEMALE
Primary Care Provider (PCP) Name _____________________________________________________________________________ PCP ID #
*Additional documentation will be required.
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May require additional information
VA-LG-KFHP-EN-CHG(01-12)
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