Kaiser Permanente Small Group Enrollment And Change Form

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MARYLAND
Kaiser Permanente Insurance
Kaiser Foundation Health Plan of the
Company (KPIC)
Mid-Atlantic States, Inc. (KFHP-MAS)
One Kaiser Plaza
2101 East Jefferson Street
Oakland, CA 94612
Rockville, MD 20852
KAISER PERMANENTE SMALL GROUP ENROLLMENT AND CHANGE FORM
HMO PLAN AND FLEXIBLE CHOICE OFFERINGS
INSTRUCTIONS
Welcome
Welcome to Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. (KFHP-MAS or Kaiser Permanente).
We look forward to receiving your Enrollment and Change form. If you have any questions concerning the
benefits and services that are provided by or excluded under these plan offerings, please contact a Member
Services representative at [1-800-777-7902] or [TTY 711] for the deaf, hard of hearing, or speech impaired before
signing this form.
After you have completed this form, please sign and return it to your employer’s benefits office. Do not send this
form to Kaiser Permanente unless otherwise instructed.
If you are enrolling in Medicare, there is a separate enrollment process. Please call a Member Services
representative at [1-800-777-7902] or [TTY 711] for the deaf, hard of hearing, or speech impaired for more
information.
How to complete this form. Please print
Use this form to enroll, waive, or change (add or delete) your family’s membership status. To be a subscriber, you
must live, work, or reside within our service area and you must be an employee who meets all of your employer’s
eligibility guidelines. If you elect to waive coverage, you only need to complete Sections A and C. If you have
any questions, contact your employer’s benefits office.
Section A: Applicant information
Please provide information about yourself. To indicate your choice of a primary care provider, please notate this in
the space provided.
Section B: Benefit plan requested
Please provide information for the plan that you are selecting.
Section C: Waiver of coverage
Complete this section if you voluntarily elect to waive all insurance coverage offered by your employer. You will
also need to read and sign section C.
Section D: Family information
Make sure your dependents, if offered by your employer, meet your group’s eligibility guidelines. If you have any
questions, contact your employer’s benefits office. If you know the medical record number, please provide it in the
requested space. To select a Kaiser Permanente primary care provider, please review the KFHP-MAS/KPIC
Provider Directory and enter the provider code of the primary care provider for you and each member of your
family. To obtain a directory please call a Member Services representative at [1-800-777-7902] or [TTY 711] for the
deaf, hard of hearing, or speech impaired, or visit our website at .
Maximum age/disabled dependent
Please complete this section to list any dependents who exceed your employer’s’ maximum limiting age
requirements or are disabled. You will be requested to provide additional information to document dependents that
are indicated in this section.
Dependents residing at another PERMANENT address
Please use this section to document any dependents who have a permanent address other than that of the
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.
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MD-SG-KFHP-KPIC-EN(3-15)
[CONTROL#/BARCODE]

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