Kaiser Enrollment Form
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2California Region Group Enrollment/Change Form
Please print or type in black ink only. See instructions on reverse before completing this form. Retain last copy
for your records and use as a temporary ID after the effective date. (See * footnote on reverse.)
TO BE COMPLETED BY EMPLOYER
Company name
Date of hire
Group number
Enrollment unit
Effective date of enrollment or coverage
NEW ENROLLMENT Check one:
New purchaser
Open enrollment (complete sections A, B, C, D)
New hire (complete sections A, B, C, D)
Other (please specify)
Loss of other coverage (complete sections A, B, C, D)
Date of event
PLAN Check one:
HMO
Deductible Plan
IF MAKING A CHANGE, COMPLETE THE FOLLOWING:
Add dependents (complete sections A, B, D)
Delete dependents (complete sections A, B, D)
*Reason:
(see Change Reason Table) Event date:
Name change (complete sections A, B, D) From:
To:
Address (complete section A)
Telephone (complete section A)
A. EMPLOYEE INFORMATION
Name (Last, First, MI)
Former last name (if any)
Home address
Apt. no. City
State
ZIP
Home phone
Work phone
Medical Record no. (if known)
M
F
Gender
E-mail
Social Security no.
Date of birth
Preferred spoken or written language (optional) Ethnicity (optional)
B. FAMILY INFORMATION For additional dependents, attach a separate sheet and please put the
employee’s name at the top. (Last, First, MI)
Add
Delete
Spouse
Domestic partner
Gender
Social Security number
M
F
Spouse/Domestic partner name:
Date of birth
Medical Record number
Former last name (if any):
Add
Delete
Child
Student
Gender
Social Security number
M
F
Dependent name:
Date of birth
Medical Record number
Relationship:
Add
Delete
Child
Student
Gender
Social Security number
M
F
Dependent name:
Date of birth
Medical Record number
Relationship:
Do any of your dependents above live at another address?
Yes
No If yes, complete the following:
Name(s) (Last, First, MI):
Address:
C. OTHER COVERAGE INFORMATION:
Including yourself, do any of the persons listed above have other coverage?
Yes
No
Name
Insurance carrier name
Policy no./Effective date
Phone no.
D. Kaiser Foundation H ealth Plan Arbitration Agreement: I understand that (except for Small Claims
Court cases, claims subject to a Medicare appeals procedure, and, if my Group must comply with
Employee Retirement Income Security Act regarding certain benefit related disputes) any dispute
between myself, my heirs, or other associated parties on the one hand and Health Plan, its health care
providers, or other associated parties on the other hand, for alleged violation of any duty arising out of
or related to membership in Health Plan, including any claim for medical or hospital malpractice, for
premises liability, or relating to the coverage for, or delivery of, services or items, irrespective of legal
theory, must be decided by binding arbitration under California law and not by lawsuit or resort to court
process, except as applicable law provides for judicial review of arbitration proceedings. I agree to give
up my right to a jury trial and accept the use of binding arbitration. I understand that the full Arbitration
provision is contained in the Evidence of Coverage.
Employee/Applicant signature
Date Employer signature
Date
*Additional documentation may be required.
White copy - Kaiser Permanente
Yellow copy - Employer
Pink copy - Employee
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