Kaiser Permanente Small Group Enrollment And Change Form Page 5
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MARYLAND
Do any of your dependents above permanently reside at another address? Yes** No
If yes, please complete the following:
Dependent last name
First name
M.I.
Home address
Apt. number
City
State
ZIP code
**If additional space is needed, please use another form and attach it to this form.
E. OTHER COVERAGE
Yes No
Including yourself, do any of the persons listed below have other health coverage?
Name
Insurance carrier name
Policy number
Telephone number
Yes No
Are you or any of your dependents eligible for Medicare?
F. SUBSCRIBER SIGNATURE
Request for enrollment
I hereby apply, on behalf of myself and each dependent listed above for the health coverage indicated. If this form is
accepted, coverage will be provided according to the terms and conditions of my employer’s contract with KFHP-
MAS/KPIC, I agree to be bound by that contract. If subscription charges are required by my employer, I agree to pay
required subscription charges to my employer.
Request for cancellation
I hereby request on behalf of myself and each dependent listed above, that my coverage be cancelled.
WARNING: 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.
If you have any questions concerning the benefits and services that are provided by or excluded under this
agreement, please contact a membership services representative before signing this enrollment card.
I have carefully read this form and agree to its terms. The recorded answers on this form are, to the best of my knowledge
and belief, full, complete, and true as of this date.
This information is subject to verification. Failure to complete any section may delay the processing of your form and/or
claims payment.
Employee/applicant signature
Date
G. 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
Phone number
Employer signature
Date
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MD-SG-KFHP-KPIC-EN(3-15)
[CONTROL#/BARCODE]
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