Account Change Form - Kaiser Permanente For Individuals And Families Page 4

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Sign the Kaiser Foundation Health Plan Arbitration Agreement

I understand that (except for Small Claims Court cases, claims subject to a Medicare appeals procedure or the

ERISA claims procedure regulation, and any other claims that cannot be subject to binding arbitration under

governing law) any dispute between myself, my heirs, relatives, or other associated parties on the one hand

and Kaiser Foundation Health Plan, Inc. (KFHP), any contracted health care providers, administrators, or other

associated parties on the other hand, for alleged violation of any duty arising out of or related to membership in

KFHP, including any claim for medical or hospital malpractice (a claim that medical services were unnecessary

or unauthorized or were improperly, negligently, or incompetently rendered), for premises liability, or relating to

the coverage for, or delivery of, services or items, irrespective of legal theory, must be decided by binding arbi-

tration 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 our right to a jury trial and accept the use of binding

arbitration. I understand that the full arbitration provision is contained in the Membership Agreement, Disclosure

Form, and Evidence of Coverage.

Subscriber or parent or legal guardian for a member under age 18

Date (mm/dd/yyyy)

Spouse/domestic partner

Date (mm/dd/yyyy)

Dependent (18 or older)

Date (mm/dd/yyyy)

Dependent (18 or older)

Date (mm/dd/yyyy)

Dependent (18 or older)

Date (mm/dd/yyyy)

Dependent (18 or older)

Date (mm/dd/yyyy)

Sign the Form

I understand that if I knowingly provide false, incomplete, or misleading information on this Account Change Form for the purpose of obtaining coverage,

my coverage may be rescinded, meaning that my contract will be declared null and void as if it had never occurred.

For all account and plan changes, the subscriber and any new dependents 18 or older must sign.

Subscriber/new subscriber (parent or legal guardian for a member under 18)

Date

Spouse/domestic partner (18 or older)

Date

Dependent (18 or older)

Date

Dependent (18 or older)

Date

Dependent (18 or older)

Date