Fillable Documentation Of Triggering Event Form

Individual and Family Plans

Documentation of triggering event form

Who should use

If you have experienced a triggering event, you need to complete this form, choose your

triggering event, and provide copies of supporting documents. Submit this form and your

this form?

supporting documentation along with your Application for Health Coverage or Account Change

Form and first month’s premium (if applicable).

How to use

Fill out pages 2 and 3 of this form and submit them with your documentation and your

application or Account Change Form.

this form

You can submit your paper application or Account Change Form by fax or mail, or you can apply

•

online at You must submit this form and your documentation by fax or mail.

Mail: Kaiser Permanente for Individuals and Families

P.O. Box 23219

San Diego, CA 92193-9921

To submit documentation for new applicants

Fax: 1-866-816-5139

To submit documentation for Account Change Forms

Fax: 858-614-3344

If you apply online, be sure to write down your application ID number. If you didn’t write it

•

down, you can log into your account to get it.

You have 10 calendar days (or until the end of your special enrollment period, whichever

•

comes first) to submit this form and your supporting documentation. If you apply by mail or

fax, you must submit this form and your supporting documentation together with your paper

application or Account Change Form.

New applicants, if we don’t receive this form and your supporting documentation along with

•

your application, it may be canceled. You may reapply by submitting the form and supporting

documentation, but only within your special enrollment period, and your effective date may

be different.

Current Kaiser Permanente members, if you are making a change due to a triggering

•

event, you must submit this form and supporting documentation with the Account Change

Form within 10 calendar days of submitting a request to make a plan change or by the end

of your special enrollment period, whichever comes first. To request an Account Change Form,

please call 1-800-494-5314. (For TTY, call 711).

On the first page of your supporting documentation, be sure to include the following

•

information for the primary applicant:

1. First and last name, as listed on the application or Account Change Form

2. Kaiser Permanente medical record number (if you have one)

3. Home address

4. Date of birth

Need help?

For more details about enrolling during a special enrollment period, please refer to your

Enrolling During a Special Enrollment Period guide.

For help completing this form, please call 1-800-494-5314 or contact your agent or broker.

(For TTY, call 711).

60433609 California January 2017

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Documentation Of Triggering Event Form - 2017

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