Enrollment Application Form (Page 2 of 2) in pdf

Enrollment Application Instructions

Instructions for the Subscriber:

1. Review the Kaiser Permanente ZIP Code Service Areas on page 3 to make sure your home ZIP

code is listed.

2. Check the box for your group’s plan on the cover of this booklet and on your Temporary Membership

ID, located on page 5.

3. Complete Section B of this Enrollment Application. Be sure to complete all fields to ensure we have

your current information and can find any prior membership records. Please print clearly in black ink.

4. Complete Section C of this Enrollment Application for any dependents you wish to enroll.

Kaiser Permanente will verify the eligibility of these dependents during the enrollment process.

5. Check with your employer to see if you are required to complete the Health Questionnaire in Section D

of this Enrollment Application (required for groups with 6 – 15 enrolling employees only). If you are

required to complete Section D, please follow the instructions at the top of page A-2.

6. Sign and date the bottom of page A-1 (and page A-3, if applicable).

7. Keep a copy of page A-1 of this Enrollment Application, to be used with your Temporary Membership

ID when seeking health care services.

Instructions for the Employer:

1. Complete all fields in Section A to ensure we have correct account and enrollment reason information.

Always indicate the appropriate enrollment reason. For “other” enrollment requests, write in the

reason from the table below. Be sure to include the event date, where requested.

If this enrollment is part of your new group set-up with Kaiser Permanente, check “New Purchaser.”

Enrollment Reason Table

Enrollment Reason

Event Date

Part-Time to Full-Time Status

Effective Date of Full-Time Status

Loss of Coverage

Date Coverage Was Lost

Moved into Service Area

Move Date

Rehire

Date of Rehire

Return from Layoff/Leave of Absence

Return Date

Return from Military Duty

Return Date

2. The employer is responsible for confirming all information on page A-1 of this Enrollment Application

prior to submission. Provide each employee with a copy of page A-1, to be used with their

Temporary Membership ID.

3. For groups with 6 – 15 enrolling employees only: The employees who enroll as part of your new

group set-up are required to complete the Health Questionnaire in Section D, which will be used

to determine your group’s rate. To protect the privacy of your employee, this application must

remain sealed and can only be opened by an authorized Kaiser Permanente representative.

NOTE: All enrollments will be made in accordance with the contractual agreement between the

purchaser and Kaiser Permanente.

012 HMO 02-3259 (rev. 6/03)

A-2

Enrollment Application Form Page 2

Related Articles

Related forms

Related Categories