Employee Change Form - Kaiser
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3Small Business Accounts
EmployEE ChAngE Form
Fax number: 1-800-369-8010
Please see page 3 for detailed instructions on filling out this form.
Fill in all areas below using black ink.
A. Customer information
Company name
Customer ID
Company contact
Enrollment unit
Contact phone number*
Fax number*
E-mail*
B. requested changes
q Add dependents (Complete sections C,D,E.)
Reason____________________________________ (See “Change reason table.”)
Event date__________________
q Delete dependents (Complete sections C,D,E.)
Reason____________________________________ (See “Change reason table.”)
Event date__________________
q Name change (Complete sections C,D,E.) From _____________________________ To _________________________
q Address (Complete section C)
q Telephone (Complete section C)
C. Employee information
Name (Last, First, MI)
Medical record number
Home address
Apt. no.
City
State
ZIP
Home phone*
Work phone*
Social Security number
E-mail*
For more information, call 1-800-790-4661. Group administrators, press 2.
Southern California brokers, press 3. Northern California brokers, press 4.
For recertification questions, call toll free 1-877-490-4983.
Recertification fax number: 1-866-233-7847
Mail to: Kaiser Permanente – Small Business, 393 E. Walnut St. (BRBK), Pasadena, CA 91188
*By giving us your contact information, you agree to be contacted by a Kaiser Permanente representative by phone, fax, or e-mail.
Small Business Marketing
page 1 of 3
60050822 Sept. 2010
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