Kaiser Permanente Federal Cobra Enrollment Form printable pdf download

COBRA Enrollment Form

Please print or type in black or dark blue ink only. Please read the “COBRA Information Sheet” before submitting this form.

Retain a copy for your records and to use as a temporary ID card if you are a new Kaiser Permanente member.

Employer Group Coverage Information

Purchaser/Enrollment Unit Number

Please complete the following

(Your employer can provide this to you.)

information so we will know

Employer

about your employer’s account

with us. The employer from

Employee name (Last/First/MI)

which you originally obtained

COBRA should be used

Date of birth

Employee medical record number

regardless of your current

(printed on your ID card)

employer/employment status.

❏

During this employment was Kaiser Permanente your group coverage?

Yes

Enrollment Information

Reason for COBRA Enrollment

❏

Termination of Employment: Last Date of Group Coverage: MO _________ DAY _________ YEAR _________

❏

Reduction of Work Hours: Last Date of Group Coverage: MO _________ DAY _________ YEAR _________

Please check the reason for

❏

Loss of spousal or dependent status: Effective Date of Loss: MO _________ DAY _________ YEAR _________

your enrollment. NOTE: If

❍

Reason for loss:

Marriage

Divorce or legal separation

Death of subscriber

Reached maximum age ____

you are requesting a transfer

❍

Subscriber’s medical entitlement

Other ________

of an existing COBRA account

❏

Transfer of existing COBRA account from another carrier to Kaiser Permanente

from another carrier to Kaiser

Carrier’s Name & Telephone Number ________________________________________________________________________

Permanente, you must indi-

Policy Number ____________________________ Policy Term Date ____________________________

cate the original reason for

Original Enrollment Reason ________________________________ Original Start Date ________________

enrollment.

Additional Enrollment Information

❏

Qualified beneficiary on the account is disabled pursuant to US Social Security Act

❏

I am applying for Health Care Tax Credit (TAA/HCTC) through the Federal Government.

(Please attach a copy of your potential eligibility letter.)

Subscriber and Family Information

Please list all members to be enrolled in the account. With the exception of annual Open Enrollments or Special Enrollments due to HIPAA, only a spouse

and dependent children included in the prior group coverage may be enrolled as part of your COBRA account. (Attach additional sheet, if needed.)

Subscriber Information

Name: (Last/First/MI)

Social Security number

Date of birth

Gender

Medical record number

(circle one)

Address: (Street/City/State/ZIP)

Family Information

Day phone number

Evening phone number

Email address (for enrollment purpose only)

Family Information

Spouse or

Name: (Last/First/MI)

Role

Social Security number Date of birth

Gender

Medical record number

(circle one)

domestic

❍

Spouse

partner

❍

Domestic

(if eligible)

partner

❍

Dependent

Child

❍

Student

❍

Child

Dependent

❍

Student

I, on behalf of myself and my family members listed on this Form, if any, agree to be bound by the benefits, co-payments, deductibles, exclusions, limitations

and other terms and conditions of the Group health plan documents, including the Evidence of Coverage. I have reviewed the statements on this form and

they are true and correct. The Health Plan reserves the right to rescind or terminate coverage if any material misrepresentation is made in this Form.

Note: Use of binding arbitration does not apply to Kaiser Permanente Insurance Company or Out-of-Network service disputes

Kaiser Permanente Arbitration Agreement: I understand that (except for small claims court cases, claims subject to a Medicare appeals procedure, and,

if my Group must comply with ERISA, 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 full arbitration provision is contained in the Evidence of Coverage.

___________________________________________________________________________________________

____________________________________

Signature

Date