Enrollment Form - Kaiser
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2ENROLLMENT 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
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Company name*
Effective date of coverage*
Group number*
Enrollment unit/plan*
Part I:
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Existing policy (Complete Part II and sections A, B, C.)
New purchaser (Complete sections A, B, C.)
Part II: Enrollment reason* (Please check one.)
Date of hire*
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Date
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New hire
Part time to full time
Other ___________________________________________________
Date
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Open enrollment
Loss of coverage
Date
Event date
To be completed by EMPLOYEE
A Are you now or have you ever been a member of, or received care from, Kaiser Permanente? � Yes � No
In which state?
If so, what is/was your medical record number (if known)?
Former name/Maiden (if any)
Name (Last, First, MI)*
Home address*
Apt. no.
City
State
ZIP
Home phone*
Work phone
Social Security number (optional)
Date of birth*
E-mail
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F
Gender*
Preferred spoken or written language (optional)
Ethnicity (optional)
B Family information
For additional dependents, attach a separate sheet and please put the employee’s name at the top.
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Gender
Social Security number
Spouse
Domestic partner
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F
Name (Last, First, MI):
Date of birth MM/DD/YY
Medical record number
Former last name (if any):
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Gender
Social Security number
Child
Student
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F
Name (Last, First, MI):
Date of birth MM/DD/YY
Medical record number
Relationship:
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Gender
Social Security number
Child
Student
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F
Name (Last, First, MI):
Date of birth MM/DD/YY
Medical record number
Relationship:
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Gender
Social Security number
Child
Student
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M
F
Name (Last, First, MI):
Date of birth MM/DD/YY
Medical record number
Relationship:
Do any of your dependents listed above live at another address? � Yes � No
If yes, complete the following:
Name (Last, First, MI)
Address
C Kaiser Foundation Health Plan 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 the 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 the Health Plan, 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 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.
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Employee/Applicant signature*
Date*
*Required
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