Kaiser Permanente Small Group Enrollment And Change Form Page 3
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MARYLAND
KAISER PERMANENTE SMALL GROUP ENROLLMENT AND CHANGE FORM
HMO PLAN AND FLEXIBLE CHOICE OFFERINGS
Company name
Effective date
Date of qualifying event
Group number
New enrollment
Qualifying life event
Change of coverage
Employee termination
Self only
COBRA
Add spouse/domestic partner*
Remove spouse/domestic
Self and dependent(s) Rehire/reinstatement
Add dependent child*
partner*
Remove dependent child*
Open enrollment
Waiver
Name change*
Cancel coverage
New hire
Other ____________
Other ___________________
A. APPLICANT’S INFORMATION. Must be completed by the employee
EMPLOYEE LAST NAME
FIRST NAME
MI
SUFFIX
ADDRESS
APARTMENT #
CITY
STATE
ZIP CODE
HOME PHONE
WORK PHONE
Social security number
Date of birth
--
/
/
Male
Female
Email address
Primary Care Provider (PCP) name
PCP ID#
Full-time Part-time
1099 Contractor
Have you or any dependents requesting coverage ever
Check One:
Seasonal Temporary Retiree
been covered as a member of KFHP-MAS?
Yes
No
If you do not physically work at your employer’s address, please provide your working address:
__________________________________________________________________________________________________
B. BENEFIT PLAN REQUESTED
Choose only one Small Group Health Plan selected by your employer (which includes pediatric dental essential health benefits
and adult preventive and discounted dental benefits)
MEDICAL
DENTAL ENHANCEMENTS (OPTIONAL)
Product
Service delivery options
[HMO]:
Signature
Select
Employer-selected adult dental rider
[Deductible HMO]:
Signature
Select
Dental benefits are underwritten by KFHP-MAS
[HDHP]:
Signature
Select
and administered by Dominion Dental USA, Inc.
[Added Choice POS]:
Signature
Select
Signature
[Flexible Choice]:
Plan Selected:_______________________________________________________________________________________
HMO, Deductible HMO, HDHP, Added Choice POS, and Flexible Choice (Tier 1 - HMO) benefits are underwritten by KFHP-MAS.
Flexible Choice (Tier 2 – PPO & Tier 3 - Out-of-network) benefits are underwritten by KPIC. For certain HDHP plans the employer
is required to open and contribute to HSA or HRA accounts for employees.
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*Additional documentation may be required.
MD-SG-KFHP-KPIC-EN(3-15)
[CONTROL#/BARCODE]
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