Fillable Enrollment Form (Page 2 of 2) in pdf

Guidelines for completing this form

1. Complete all applicable fields on the form. Use only dark

5. Do not submit payment with this form. Your former

blue or black ink. Please print clearly.

employer will instruct you on how to make your

payments.

2. Complete and sign this enrollment form. The subscriber

(employee) must sign the form; or, in the case of spouse

6. For enrollment in a COBRA account, check with your

domestic partner (if eligible) or dependent making their

former employer as to where to submit the form. Do not

own individual election, such individual must sign the

mail or fax it to us.

form. With respect to an individual under the age of 18,

7. Be sure to include the Social Security Numbers of any

the parent or legal guardian must sign the form. Include

members who are, or have ever been, Kaiser

information on all dependents to be covered.

Permanente members. We will use this number to

3. The subscriber (employee) on the group coverage

ensure that they retain the same Medical Record Number

account is not required to be enrolled in the COBRA

that they may have been assigned in the past.

account. If the employee does not enroll in COBRA,

8. Only new members will receive an ID card. Existing

please specify who the new subscriber on the account

members will not receive new cards. Please continue to

should be in the “Subscriber Enrollment Information”

use your existing card.

section of the form.

9. If you are transferring your existing COBRA account from

4. Your spouse (or domestic partner, if eligible) or

another carrier to Kaiser Permanente during Open

dependent children are eligible to enroll if they were

Enrollment, be sure to include the original reason why

covered under your Kaiser Permanente group plan.

you were initially eligible for your COBRA coverage, and

Dependents may be added only during open enrollment,

identify your other carrier’s name and your original start

or under the special enrollment provisions of HIPAA

date.

(Health Insurance Portability and Accountability Act of

1996).

CSC May-2011

6906-001-102

Please read instructions. Both the employer and the employee must complete fields on

this form to request enrollment in a Kaiser Permanente group COBRA account.

Enrollment Form Page 2

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