Subscriber Termination And Transfer Form - Kaiser Page 2
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2Subscriber Termination and Transfer Form
Additional processing rules
1. Subscriber terminations and transfers may only be requested by staff authorized by the purchaser to
change membership records.
2. Complete all fields.
3. For transfer reason code 11, a completed Group Enrollment/Change Form signed by the subscriber is
required to update the subscriber’s change of address.
4. For transfer reason codes 14 and 15, a completed and signed Group Enrollment/Change Form is required
from the subscriber to add or remove dependents from the subscriber’s account.
5. This form cannot be used for new subscriber enrollments and/or dependent additions or terminations.
New subscriber enrollments and dependent changes require a Group Enrollment/Change Form completed
and signed by the subscriber.
6. Subscriber transfers can only be performed across enrollment units within the same purchaser ID
and region.
a. The same form may be used to report transfers if they are originating from the same enrollment unit.
b. A separate form is needed for each enrollment unit if the transfers are originating from different
enrollment units.
7. Kaiser Permanente’s standard retroactivity policy is the current month plus two months. Submit requests
within these guidelines unless your contract states otherwise.
8. Fax the completed form to one of the following fax numbers. If you fax the form, do not mail it.
a. For Northern California accounts: (858) 614-3344
b. For Southern California accounts: (858) 614-3345
9. If you choose to mail the completed form, send it to the “Membership” address indicated on your billing
statement. Do not mail with your payment or processing will be significantly delayed.
10. This form is not required for terminations processed through our secure online account services Web site
unless the site rejects the transaction.
11. Be sure to retain a copy for your records.
Termination effective dates
When a member is no longer eligible for coverage, membership terminates on the last day of that month at 11:59 p.m.
unless your group has an agreement with us to terminate at a time other than on the last day of the month. For example,
a member who terminates employment on December 2 will be covered until December 31 at 11:59 p.m. (PST). On this
form, you will enter the “Termination effective date” as January 1 because the termination effective date will be the first
minute after the member’s coverage ended on December 31 at 11:59 p.m.
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0506-0013-02-r03
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