Enrollment Application Form
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1
2Enrollment Application
Please print or type in black ink only. Please see instructions on reverse before completing this form.
Fields with * are mandatory for enrollment.
A. TO BE COMPLETED BY EMPLOYER
_______________________________________________________________
____________________________
________________________________
*Company or Trust Fund Name
*Purchaser Number
Enrollment Unit Number (EU)
(______)
(______)
______________________________________________________________
(
____________________
______________________
Company or Trust Fund Address
Phone Number
Fax Number
_____________________________________________________
___________________________
______________________________
Purchaser Contact
Employer ID
*Effective Date of Coverage
*
ENROLLMENT (check only one—see Enrollment Reason Table on reverse side for options)
❏ New Hire Enrollment—Date of Hire: __________________
❏ Open Enrollment
❏ Part Time to Full Time—Date: ________________________
❏ Other: ______________________ Event Date: _____________
❏ New Purchaser
B. EMPLOYEE/SUBSCRIBER INFORMATION
Are you now or have you ever been a Kaiser Permanente member? ❏ Yes ❏ No
Height ______________
If so, what is/was your Medical Record Number? __________________________________________
Weight ______________
Have you ever received care from Kaiser Permanente within the state of California? ❏ Yes ❏ No
Under what name: ______________________________________________________________________
Maiden/Other
_________ – ______ – _________
__________________________________________________
__________________________________ ___________
*Social Security Number
*Last Name
*First Name
MI
*Gender: ❏ M ❏ F
Marital Status: ❏ Married ❏ Single
________ /________ /________
*Date of Birth
___________________________
_____________________________ ____________________________________________________
Preferred Language Spoken
Preferred Language Written
E-mail Address (optional)
__________________________________________________________ _______________________________ _______ ____________
*Street Address
*City
*State
*ZIP Code
(______) ____________________ (______) _____________________ ___________________________ Employment Status:
Day Phone ❒ Home ❒ Work
Evening Phone ❒ Home ❒ Work Employee ID
❏ Working ❏ Retired
C. LIST FAMILY MEMBERS TO BE ENROLLED (attach additional sheet, if needed)
Medical Record
*Social Security
*Date of Birth
Number
*Last Name
*First Name
MI
*Role
Number
MM /DD /YY
*Gender
if Known
Height Weight
Spouse
❏ Spouse
❏ M
❏ Domestic
/
/
❏ F
❏
Maiden/Other:
Partner
❏ Child
❏ M
Dependent
/
/
❏ Student
❏ F
Relationship:
❏ Child
❏ M
Dependent
/
/
❏ Student
❏ F
Relationship:
❏ Child
❏ M
Dependent
/
/
❏ Student
❏ F
Relationship:
❏ Child
❏ M
Dependent
/
/
❏ Student
❏ F
Relationship:
❏ Check here if all dependents are at the address below.
Dependent(s’) Address (if different from subscriber’s):
Name(s)
Address
City
State ZIP Code
Kaiser Foundation Health Plan Arbitration Agreement:
I understand that, except for Small Claims Court cases, claims subject to a Medicare appeals procedure, and if your Group
must comply with ERISA regarding certain benefit-related disputes, any dispute between myself, my heirs or other associated
parties on the one hand and Health Plan, its health care providers, or other associated parties on the other hand, for alleged
violation of any duty arising out of or related to membership in Health Plan, including any claim for medical or hospital
malpractice, for premises liability, or relating to the coverage for, or delivery of, services or items, irrespective of legal theory,
must be decided by binding arbitration 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 my right to a jury trial and accept the use of
binding arbitration. I understand that the arbitration provision is contained in the Evidence of Coverage.
X
*Employee/Subscriber Signature
*Date
A-1
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