California Region Group Enrollment/change Form
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2California Region Group Enrollment/Change Form
Please print or type in black ink only. See instructions on reverse before completing this form. Make a copy for your records.
TO BE COMPLETED BY EMPLOYER
Company name
Hire date (mm/dd/yyyy)
Effective enrollment/
Group number
Enrollment unit
change date (mm/dd/yyyy)
A. ENROLLMENT/CHANGE REASON (see Change Table for assistance)
New group: ❑ Yes ❑ No
❑ New Hire (complete sections A, B, C, D)
❑ Open Enrollment (complete sections A, B, C, D)
Health Plan (Check one) ❑ HMO Plan ❑ Deductible Plan ❑ Other
❑ Loss of Other Coverage (complete sections A, B, C, D)
❑ Other (please specify)
❑ Name change (complete sections A, B, C, D) From:
To:
Event Date (mm/dd/yyyy)
B. EMPLOYEE Have you ever been a Kaiser Permanente member? ❑ Yes ❑ No
Medical Record No. (if known)
Social Security No.
Gender ❑ M ❑ F
Name (Last, First, MI)
Birth Date (mm/dd/yyyy)
Home Address
City
State
ZIP
Work Phone
Home Phone
E-mail
Ethnicity
Preferred Language
C. FAMILY For additional dependents, attach a separate sheet with employee’s name at top. (Last, First, MI)
Social Security No.
❑ Add ❑ Delete ❑ Spouse ❑ Domestic partner
Gender ❑ M ❑ F
Spouse/domestic partner name:
Birth Date (mm/dd/yyyy)
Former last name (if any):
Medical Record No.
❑ Add ❑ Delete ❑ Child ❑ Student
Gender ❑ M ❑ F
Social Security No.
Dependent name:
Birth Date (mm/dd/yyyy)
Relationship:
Medical Record No.
Social Security No.
❑ Add ❑ Delete ❑ Child ❑ Student
Gender ❑ M ❑ F
Dependent name:
Birth Date (mm/dd/yyyy)
Relationship:
Medical Record No.
Do any of dependents above live at another address? ❑ Yes ❑ No If yes, complete the following:
Address:
Name (Last, First, MI):
D. Kaiser Foundation Health Plan, Inc., and Kaiser Permanente Insurance Company Arbitration Agreement* :
I understand that (except for Small Claims Court cases, claims subject to a Medicare appeals procedure, and, if I am enrolled
in coverage that is subject to the ERISA claims procedure regulation (29 CFR 2560.503-1), certain benefit-related disputes*)
any dispute between myself, my heirs, relatives, or other associated parties on the one hand and Kaiser Foundation Health
Plan, Inc. (KFHP), Kaiser Permanente Insurance Company (KPIC), any contracted health care providers, administrators,
or other associated parties on the other hand, for alleged violation of any duty arising out of or related to membership
in KFHP or coverage by KPIC, including any claim for medical or hospital malpractice (a claim that medical services were
unnecessary or unauthorized or were improperly, negligently, or incompetently rendered), 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 our 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 and in the Certificate of Insurance.
* Disputes arising from any of the following KPIC products are not subject to binding arbitration: 1) Tiers 2 & 3 of the Point of Service
(POS) Plans; 2), the Preferred Provider Organization (PPO) and Out of Area Indemnity (OOA) Plans; and 3), the KPIC dental plans.
Employee/Applicant signature
Date
Employer signature
Date
0106-0040-04-r03
Revision date 05/2011
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