Student Health Plan Enrollment Application Form Page 2
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4Kaiser Permanente Student Health
Plan Enrollment/Change Form
Name:___________________________________________
Student ID:_____________________________
TO BE COMPLETED BY SCHOOL ADMINISTRATOR
School Name
Customer ID Number
Enrollment unit
Effective Date (mm/dd/yyyy)
Academic Year
A. MAKE A CHANGE (Required if making a change.)
Check those that apply:
q Terminate coverage for active military service
Date of deployment______________________
q Add or update dependent information midterm. Enter dependent information in Section C.
q Update your contact information midterm. Enter new information in Section B.
q Add coverage mid-term due to loss of coverage from another carrier. Complete Sections B, C
(if you want to enroll dependents), D, E, and F.
B. STUDENT INFORMATION
Health Plan (Check one)
q HMO
q Deductible HMO
q HMO with Added Coverage
Have you ever been a Kaiser Permanente member? (new enrollees only)
q Yes q No
Medical Record Number (if known)
Student Identification Number
Birth date (mm/dd/yyyy)
Gender
q M q F
Name (Last, First MI)
Street address
Apt. No.
City
State
ZIP
Please give the address of your place of residence while at school (if known). This address will be
used to mail your Kaiser Permanente ID card and other important Health Plan information.
Cell Phone
Home Phone
E-mail Address
Preferred Language
Ethnicity
C. DEPENDENTS
To enroll dependents, you must indicate the requested change to the account and complete all fields. We will verify the
eligibility of these dependents during the enrollment process. Be sure to include any former last name of your spouse or
domestic partner. Also indicate the appropriate role. The student role should be marked only if the dependent qualifies as
an “overage dependent” attending school. Please contact your school administrator regarding rules for overage dependent
students. A completed Student Certification form may be required.
For additional dependents, attach a separate sheet with your name at the top. (Last, First MI)
q Add q Delete
q Spouse q Domestic Partner
Gender q M q F
Social Security Number _________________
Spouse/domestic partner name________________________________________ Birth Date (mm/dd/yyyy)_________________
Former last name (if any)______________________________________________ Medical Record Number (if known)_________
q Add q Delete
q Child q Student
Gender q M q F
Social Security Number _______________________________
Dependent name_____________________________________
Birth Date (mm/dd/yyyy) ________________________________
Relationship__________________________________________
Medical Record Number (if known) _______________________
q Add q Delete
q Child q Student
Gender q M q F
Social Security Number _______________________________
Dependent name_____________________________________
Birth Date (mm/dd/yyyy) ________________________________
Relationship__________________________________________
Medical Record Number (if known) _______________________
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