Fillable Student Health Plan Enrollment Application Form (Page 3 of 4) in pdf

Kaiser Permanente Student Health

Plan Enrollment/Change Form

Name:___________________________________________

Student ID:_____________________________

C. DEPENDENTS (continued)

Do any of the above dependents live at another address?

q Yes q No If yes, complete the following:For an additional

dependent, who lives at another address, please use the space below. If you have more than one additional dependent,

please attach a separate sheet with your name at the top (Last, First MI) and the dependents’ names (Last, First MI) and

addresses.

Name (Last, First MI)________________________________

Address_________________________________________________

D. ELECT COVERAGE (required)

Be sure to review your school’s rate, coverage dates, and break date information (if applicable) at before

checking the box in this section.

q By checking this box, you are electing coverage beginning with the current school term through the end

of the academic year. You are also acknowledging that you have reviewed the coverage dates, rates, and

break dates (if applicable) for your school at StudentNet (). Coverage will continue

through the end of the academic year unless you actively waive coverage, fail to pay your premiums, or

terminate coverage. You are required to re-enroll in the Student Health Plan once per academic year.

E. AUTHORIZATION FOR USE AND DISCLOSURE OF HEALTH INFORMATION

I authorize Kaiser Foundation Health Plan, Inc. to disclose to an authorized representative of my school information about

my enrollment or disenrollment in, and my payment of premiums for, Student Health Plan. My school may use this protected

health information (PHI) only for the purpose of verifying:

(i) My enrollment in, or disenrollment from, Student Health Plan; and

(ii) My payment of premiums for Student Health Plan.

I understand that my eligibility for membership in Student Health Plan is based in part on my school’s verification of my

status as an enrolled student eligible to participate in Student Health Plan and a requirement of eligibility is to provide the

above authorization. If I do not provide the authorization, I understand that I will be unable to enroll in Student Health Plan.

DURATION: The above authorization shall become effective immediately and shall remain in effect for one year from the date

of my signature below unless a different date is specified here: _______________

REVOCATION: This authorization is also subject to written revocation by me at any time. The written revocation will

be effective upon my request, except to the extent that the disclosing party or others have acted in reliance upon this

authorization before my revocation.

REDISCLOSURE: I understand that the recipient of my PHI may not lawfully further use or disclose it unless:

(i) Another authorization is obtained from me, or

(ii) Such use or disclosure is specifically required or permitted by law.

I understand, however, that any PHI disclosed in reliance upon this authorization that is further redisclosed may no longer be

protected by the Health Insurance Portability and Accountability Act of 1996.

___________________________________________________

__________________________________

Printed name

Date

______________________________________________________________________________________________

Signature

If this form is to be signed by anyone other than the individual (student) who is the subject of the information to be

disclosed, the individual who signs must provide all the information requested below.

q I am authorized to sign the authorization on behalf of the student/subscriber.

___________________________________________________

_________________________________________________

Printed name

Date

___________________________________________________

_________________________________________________

Signature

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Student Health Plan Enrollment Application Form Page 3

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