Subscriber Termination And Transfer Form - Kaiser

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Subscriber Termination and Transfer Form
Use this form for billed purchasers to request subscriber/account terminations and/or subscriber/account transfers from one
enrollment unit to another within the same purchaser ID and region. Do not use this form for new subscriber enrollments
and/or dependent additions or terminations.
Purchaser information
Today’s date ________________________________________________________________________________________________
Purchaser name ____________________________________________________________________________________________
Purchaser/enrollment unit number _____________________________________________________________________________
Billing contact name (please print) __________________________________
Telephone number _______________________
E-mail address (optional) __________________________________________
Fax number _____________________________
Check here if billing contact information is new
Termination or transfer requests
(refer to the processing rules on page 2)
Subscriber name
Subscriber Social
Indicate new
medical record
Security number
or transfer
or transfer
enrollment unit
effective date reason code
(required for transfers only)
(see page 2)
(select from
table below)
1-Employment terminated
1-Employment terminated
1-Employment terminated
1-Employment terminated
Termination reason codes
1–Employment terminated
3–Leave of absence
5–Military duty
7–Enrolled in error
9–Subscriber requested
2–Subscriber retired
6–Subscriber deceased
8–Loss of disabled status
Transfer reason codes
(refer to page 2 for additional information)
13– Employment status change:
14– Marital status change:
15– Dependent status change:
10– Open enrollment
• Start or termination of
• Marriage
• Birth
plan changes
employment of the
• Death of employee’s
• Adoption or placement for adoption
employee’s spouse
• Death of dependent child
11– Change in geographic
• Start of, or return from,
• Divorce or annulment
• Newly eligible dependents due to employer
service area*
leave of absence
• Legal separation
change in eligibility rules
• Change from salaried to
• Dependent loss of eligibility due to age, student
12– Loss of coverage:
hourly or vice versa
status, or marriage
• Spouse or dependent
• Change from part-time to
loss of coverage
full-time or vice versa
• Reaching lifetime
• Employee retirement
• Strike or lockout
• Significant change in health
coverage of the employee
or spouse attributable to the
spouse’s employment
*For transfer reason code 11, submit a completed Group Enrollment/Change Form signed by the subscriber providing the new address.
For transfer reason codes 14 or 15, submit a completed Group Enrollment/Change Form signed by the subscriber if adding or removing a
dependent(s) from the subscriber’s account. Refer to page 2 for additional information.


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