Kaiser Permanente Small Group Enrollment And Change Form Page 2
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5MARYLAND
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
Section E: Other coverage
Tell us if you, your spouse/domestic partner, if offered by your employer, or other family dependents are covered
by other group health insurance plans. This may occur when both spouses/domestic partners are employed and
have health care benefits from one or more health plan(s). If you or your family are covered by more than one
health plan, you may be able to save money while improving your coverage. If you are covered by two plans that
include a Coordination of Benefit (COB) provision, you may be able to eliminate some of your out-of-pocket
expenses for approved services now only partially covered by those plans. If the Coordination of Benefits
provisions apply to you, your signature on this form will permit KFHP-MAS/KPIC to bill any other health care policy
that is determined to be the primary carrier in accordance with the National Association of Insurance
Commissioners (NAIC) guidelines including, but not limited to Medicare and Workers’ Compensation, so long as
you are enrolled in the primary plan and such plan remains primary to KFHP-MAS/KPIC plan. Your signature
authorizes KFHP-MAS/KPIC 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 [1-
800-777-7902] or [TTY 711] for the deaf, hard of hearing, or speech impaired.
Section F: Subscriber signature
Review and sign this form. Before doing so, please make certain you have read all coverage materials and have
selected a primary care provider. Failure to complete all relevant parts of this form may delay or prevent
enrollment and the issuance of a member ID card.
Section G: Employer Authorized Representative
To be completed by the employer.
MISREPRESENTATION
Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who
knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison. In addition, KFHP-MAS/KPIC may deny insurance benefits if false
information materially related to a claim was knowingly or willfully provided by the applicant.
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MD-SG-KFHP-KPIC-EN(3-15)
[CONTROL#/BARCODE]
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