Kaiser Enrollment Form Page 2
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2California Region Group Enrollment/Change Form
General instructions:
Instructions for completing employer and new
enrollment sections and sections A through D:
1. Please print firmly and legibly in black ink.
To be completed by employer: The employer
must complete all fields to ensure we have correct
2. To be enrolled, you must reside within one of
account and enrollment reason information.
the ZIP codes listed on the enclosed sheet.
The employer is responsible for confirming all
3. The employer must complete the first section
information submitted by the subscriber, especially
labeled “To be completed by employer.”
effective dates as they affect the Health Plan dues.
4. The employer is responsible for confirming
If making a change, the subscriber must always
all information prior to submitting, especially
complete this section, even when making minor
effective dates as these affect your Health
changes to the account. This ensures our
Plan dues.
information is current. Please mark the box if
5. The employee/subscriber must complete
your address is new.
Sections A through C. See right column for
Section A: The subscriber must complete this
detailed instructions.
section.
6. Be sure to sign and date the bottom of the
Section B: The subscriber must indicate the
form.
requested change they are making to their account
7. Once the form is complete (including completed
and complete all fields for any dependents being
employer section), the subscriber should retain
enrolled. We will verify the eligibility of these
the last copy for their records to use as a
dependents during the enrollment process. Be
temporary ID card, after the effective date.
sure to include any former last names for both
spouses and dependents. Also indicate the
8. All changes to accounts, including effective
appropriate role. The student role should only be
dates and child or student status, will be made
marked if the dependent qualifies as an “overage
in accordance with the contractual agreement
dependent” attending school. Please contact your
between the purchaser and Kaiser Permanente.
employer regarding their rules for overage
dependent students. A completed Student
Certification Form may be required.
Sections C, D: The subscriber must complete
these sections.
Change Reason Table
Add dependent reason
Event date
Acquired student status*
Date student status was obtained
Family adoption*
Date of adoption
Loss of coverage
Date coverage was lost
New spouse (marriage)*
Date of marriage
Moved into service area
Move date
Newborn addition
Date of birth
Open enrollment
Open enrollment effective date
Delete dependent reason
Event date
Loss of student status
Date of status change
Divorce
Date of divorce
Member deceased*
Date of death
Delete dependent(s)
Dependent termination date
Open enrollment
Open enrollment effective date
*Additional documentation may be required.
0106-0040-01-r03
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