Kaiser Permanente Federal Cobra Enrollment Form (Page 2 of 2) in pdf

Guidelines for completing this form

Be sure to read the enclosed Information Sheet as well as your Notice of Right to Elect COBRA Continuation Coverage and

Important Information About Your COBRA Continuation Coverage Rights. If you did not receive any of these documents, please

contact your employer or our Member Service Call Center at 1-800-464-4000.

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

6. Do not submit payment with this form. If enrolling in a

blue or black ink. Please print clearly.

Kaiser Permanente-administered COBRA account, you

will receive an invoice once your enrollment is processed.

2. Complete and sign this enrollment form. The subscriber

If enrolling in a group-administered COBRA account,

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

your former employer will instruct you on how to make

or dependent making their own individual election, such

your payments.

individual must sign the form. With respect to an individual

under the age of 18, the parent or legal guardian must sign

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

the form. Include information on all dependents to be covered.

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

mail it to us.

3. The subscriber (employee) on the group coverage account

is not required to be enrolled in the COBRA account. If the

8. Be sure to include the Medical Record Numbers of any

employee does not enroll in COBRA, please specify who

members who are, or have ever been, Kaiser Permanente

the new subscriber on the account should be in the

members. It is very important that members retain their

“Subscriber Enrollment Information” section of the form.

Medical Record Numbers.

4. To be eligible, a spouse or dependent children have been

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

covered under your group plan. The only exception to this

will not receive new cards. Please continue to use your

is if you are transferring your existing COBRA account to

existing card.

Kaiser Permanente, are making a new election at Open

10. If you are transferring your existing COBRA account from

Enrollment, or are enrolling new dependents under the spe-

another carrier to Kaiser Permanente during Open

cial enrollment provisions of HIPAA (Health Insurance

Enrollment, be sure to tell us the original reason for your

Portability and Accountability Act of 1996).

COBRA coverage, and identify your other carrier’s name

5. For enrollment in a COBRA account, obtain the applicable

and your original start date.

Health Plan dues rate from your Personnel or Human

Resources department.

012 AMT 01-3006/C (09/2002)

6906-0001-01-r03

Federal COBRA

Enrollment Form

Please read instructions and complete form to request enrollment

in a Kaiser Permanente COBRA account.

Kaiser Permanente Federal Cobra Enrollment Form Page 2

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