Page 1 of 6
KFHP-KPIC-APP-GA-2019-1
Small Group 60990908 January 2019
Georgia Small Group
EMPLOYER APPLICATION
Email application to your Kaiser Permanente
representative or your broker.
Requested effective date
3A
EMPLOYER ELIGIBILITY
In determining the number of employees or eligible employees, affiliated companies that are eligible to file a combined tax return for purposes of state taxation
shall be considered 1 employer.
Is your company affiliated with another company and eligible to file a combined tax return?
Yes No If Yes, please provide below:
Company name
Affiliate Subsidiary
Address City State ZIP
Federal tax ID number Phone
( ) –
/ /
2 OTHER MEDICAL COVERAGE
Does your company or affiliated company(ies) have or has it ever had group coverage directly through Kaiser Permanente? If Yes, please provide the group
number and company name.
Yes No Group #: Company name:
Does your company currently have active group health coverage?
Yes No Name of carrier: Renewal date: / /
1 ABOUT BUSINESS
Legal business name
(as stated on your local business license, quarterly wage and tax report, corporate or partnership documents)
Doing business as (DBA)
Physical street address (no P.O. boxes) City State ZIP County
Phone
( ) –
Fax
( ) –
Type of business
Corporation Sole proprietorship Partnership Limited liability company (LLC) Other:
In business since (mm/dd/yyyy)
/ /
Federal tax ID (EIN) number SIC code (4 digits) Website
All employees must be covered by workers’ compensation, unless not required to be covered by law. You’re not eligible to apply for coverage if you don’t have
workers’ compensation, unless you’re exempt. I attest that the following information is correct.
Yes, my company has workers’ compensation. Pending
If Yes or Pending, name of carrier: ______________________________________
Policy # __________________________________________
(indicate unknown or pending as applicable)
Exempt from providing workers’ compensation for the following reason: _____________________________________________________________
01/02/2012
Page 2 of 6
KFHP-KPIC-APP-GA-2019-1
Small Group 60990908 January 2019
Georgia Small Group
EMPLOYER APPLICATION
Business name (please print):
6 ERISA STATUS
Is your company subject to ERISA?
3
Yes No If you don’t select an answer, we’ll record your status as Yes.
ERISA is a federal law that sets minimum standards for employee benefit plans established by private employers and employee organizations. Many group
health plans are subject to ERISA, although government and church plans generally aren’t. If you’re unsure of your group health plan’s ERISA status, we
recommend that you consult with your financial or legal advisor before responding.
7 EMPLOYER PREMIUM CONTRIBUTION
Your contribution to coverage can be a percentage or a fixed dollar amount. Your minimum contribution must be at least 50% of the “employee only”
monthly premium for the lowest-priced Kaiser Permanente medical plan offered by you, the employer.
Percentage of the premium is based on the following (select 1 only):
Lowest plan offered All plans offered Specific plan offered:
Employer contribution (50%–100%): % per employee % per dependent (optional)
Employer contribution (fixed $): $ per employee $ per dependent (optional)
5 CONTINUATION COVERAGE
Did your company employ 20 or more employees for at least 50% of the workdays of the preceding calendar year (January through December), making it
subject to COBRA?
Yes No
3B
EMPLOYEE COUNT
Please provide the total number of employees (full-time and part-time).
Total ______________ Authorized company signer’s initials ______________
Note: If the total number of employees noted above is 50 or fewer, skip the following and go to section 3C.
If your total number of employees noted above is more than 50, please provide the total number of full-time and full-time-equivalent employees on the
line below. For information on calculating the number of full-time and full-time-equivalent employees (FTE), refer to healthcare.gov or your legal counsel.
To qualify for small group coverage, your company must have at least 1 but no more than 50 full-time and full-time-equivalent employees on average of the
previous calendar year.
Total ______________ Authorized company signer’s initials ______________
3C
ELIGIBLE AND ENROLLING EMPLOYEES
Please provide the total number of eligible employees. Total _________________ Authorized company signer’s initials ______________
Please provide the total number of enrolling employees. Total ________________ Authorized company signer’s initials ______________
Hours per week employees must work to be eligible for coverage:
1
______________
Employee only coverage?
2
Yes No
1
Minimum of 30 hours per week.
2
If you have 50 or more full-time or full-time-equivalent employees, you must offer dependent coverage. For more information about Employer Shared
Responsibility, see section 4980(H)(C)(2) of the Internal Revenue Code.
4 DOMESTIC PARTNER COVERAGE
Do you wish to select Domestic Partner Coverage? Yes No
Page 3 of 6
KFHP-KPIC-APP-GA-2019-1
Small Group 60990908 January 2019
Georgia Small Group
EMPLOYER APPLICATION
Business name (please print):
10 BILLING CONTACT INFORMATION
The billing contact is the person within your company to whom billing statements are addressed. This person will have access to group information, but isn’t
authorized to sign the group agreement or to make contractual changes to your account. Only 1 billing contact is allowed.
Check here if same as contract signer.
First name MI Last name
Street address City State ZIP
Office phone
( ) –
Ext. Fax
( ) –
Cellphone
( ) –
Email How should we correspond with this person?
(select 1 only)
Email Mail
9 CONTRACT SIGNER INFORMATION
There’s only 1 contract signer. This principal person is responsible for signing the group agreement, providing renewal information, and authorized to make
membership or contractual changes to your account. This address will become the group mailing address, if different from the business physical address.
First name MI Last name Title
Street address (mailing address) City State ZIP
Office phone
( ) –
Ext. Fax
( ) –
Cellphone
( ) –
Email How should we correspond with this person?
(select 1 only)
Email Mail
11 MEDICAL PLANS
Please select the plan(s) you’d like to offer. For more information on the plans listed below, contact your sales representative or agent/broker.
You’re eligible to offer a choice of plans to your employees.
Platinum
Platinum KP 0/0/20/S6
Platinum PPO 0/0/20/S6
Platinum KP 500/0/20/S6
Platinum PPO 500/20/20/S6
Gold
Gold KP 0/0/30/S6
Gold PPO 0/0/30/S6
Gold KP 1000/20/30/S6
Gold PPO 1000/20/30/S6
Gold KP 1500/0/30/S6
Gold PPO 1500/10/30/S6
Gold KP 1750/20/50/S6
Gold PPO 1750/20/50/S6
Silver
Silver KP 2000/35/50/S6
Silver PPO 2000/35/50/S6
Silver KP 3000/30/50/S6
Silver PPO 3000/30/50/S6
Silver KP 4000/30/50/S6
Silver PPO 4000/30/50/S6
Silver HDHP/3000/20/S6
Silver PPO HDHP 3000/20/S6
Silver HDHP/4000/20/S6
Silver PPO HDHP 4000/20/S6
Silver HRA/2500/30/S6
Silver PPO HRA 2500/30/S6
Bronze
Bronze KP 5250/20/40/S6
Bronze PPO 5250/20/40/S6
Bronze KP 6000/20/50/S6
Bronze PPO 6000/20/50/S6
Bronze HDHP/5000/20/S6
Bronze PPO HDHP 5000/20/S6
Bronze HDHP/6550/0/S6
Bronze PPO HDHP 6550/10/S6
Kaiser Foundation Health Plan of Georgia, Inc., underwrites the Kaiser Permanente plans. Kaiser Permanente Insurance Company (KPIC), a subsidiary of Kaiser
Foundation Health Plan, underwrites the PPO Plans.
8 RENEWAL DELIVERY PREFERENCE
We’ll deliver your Kaiser Foundation Health Plan, Inc. (KFHP)/Kaiser Permanente Insurance Company (KPIC) renewal(s) online in a PDF file at account.kp.org
unless you indicate below that you’d like your renewal(s) mailed to you.
I want to receive my renewal(s) by mail.
rrrrddddddddd
Page 4 of 6
KFHP-KPIC-APP-GA-2019-1
Small Group 60990908 January 2019
Georgia Small Group
EMPLOYER APPLICATION
Business name (please print):
12 IMPORTANT INFORMATION – PLEASE READ CAREFULLY
This is an application for coverage only. No contract for coverage will exist until Kaiser Foundation Health Plan, Inc. (KFHP), or Kaiser Permanente Insurance
Company (KPIC) has completed its review and communicated to the business applicant or the applicant’s broker that the application has been accepted and a
group health plan contract/group policy will be issued.
13 AUTHORIZED AGENT/BROKER OF RECORD FOR KAISER PERMANENTE
I assisted the applicant in submitting this application. To the best of my knowledge and belief, the employment and other information on this application is
complete and accurate. I acknowledge that I represent and am acting on behalf of my client and not for, or as, an employee of Kaiser Foundation Health Plan
or KPIC. I have explained the benefits and limitations of coverage and advised my client not to terminate any existing coverage until receiving written notice
that the coverage being applied for under the new program has been approved. I understand that I have no right to bind this coverage, or to alter terms of
the insurance.
Yes No
Agent name License number
Phone
( ) –
Fax
( ) –
Cellphone
( ) –
Email
Firm name EIN/TIN Kaiser Permanente broker firm ID
Street address City State ZIP
Agent/broker signature
X
Date
General agency
Robert Hurley
877-456-6670
916-608-6188
smb@ehealthinsurance.com
eHealthInsurance
77-0470789
11919 Foundation Place, Ste 100
Gold River
CA
95670
Robert Hurley
Date
12/06/2018
12/06/2018
Page 5 of 6
KFHP-KPIC-APP-GA-2019-1
Small Group 60990908 January 2019
Georgia Small Group
EMPLOYER APPLICATION
Business name (please print):
14 AGREEMENT AND SIGNATURE
As a company principal/corporate officer, having authority to contract with KFHP and KPIC, I agree that:
Prepaid monthly premiums will be posted to Kaiser Permanente’s account by the due date on the Kaiser Permanente billing statement.
My company will use employee enrollment application forms provided or approved by KFHP and KPIC for new employees.
Employees must be full-time, working 30 or more hours per week, and earning compensation equal to a minimum of the federal minimum
wage. The eligibility data provided by my company to Kaiser Permanente will include coverage effective dates for my company’s employees
that correctly account for eligibility in compliance with the waiting period requirement in the Affordable Care Act and federal regulations, which
require that waiting periods not exceed 90 days. My company acknowledges that the effective date of coverage for new employees and their
eligible family dependents will be on the 1st of the month and won’t exceed the waiting period established by my company.
My company will abide by the contract provisions.
Approval may be withheld for any reason permitted under applicable state and/or federal law. The employer understands the licensed broker, if
any, who solicited this application was acting as an independent contractor and not as a broker of the Health Plan and/or KPIC, as applicable.
Furthermore, the broker who solicited this agreement or upon whose explanation of coverage and benefits employer relied is in fact employer’s
broker for purposes of this agreement. It’s understood that as an independent contractor and as employer’s broker that person has no right to
bind this coverage or to alter terms or conditions of any policies or any enrollment applications or to waive any requirements of Health Plan and/
or KPIC, as applicable, or to adjust any claims for benefits under this insurance for which employer is applying.
The employer acknowledges and agrees that coverage under any policy will only be as and to the extent provided, and it’s employer’s duty and
responsibility to explain this to each person for whom coverage is sought. Employer has reviewed the benefits and limitations of coverage in the
benefits summary and has explained such benefits and limitations to each person for whom coverage is sought. It’s also acknowledged and agreed
that coverage will begin only: upon the effective date inserted by Health Plan and/or KPIC, as applicable in the written notice to employer. The
absence of written approval won’t imply approval. Approval may be withheld for any reason permitted under applicable state and/or federal law.
Employer may cancel this agreement at any time upon 30 days prior written notice to Health Plan and/or KPIC, as applicable. For the duration
of coverage, employer agrees to pay premiums on a monthly basis or at such other frequency as agreed upon by Health Plan and/or KPIC, as
applicable. If Health Plan and/or KPIC, as applicable, doesn’t receive payment in full within the time allowed, this will automatically constitute
withdrawal and cancellation of all coverage. The effective date of coverage termination will be 12:01 a.m. of the first day of the billing period for
which the premium wasn’t paid when due if: (1) coverage is terminated because of nonpayment of premium in full; or (2) employer has given
prior written notice of cancellation. Coverage for the participating employees and their dependents will be continuous unless (1) the employee
terminates employment; (2) the employee or dependent ceases to be eligible; or (3) requirements of this agreement aren’t maintained by the
participating parties here-under, including employer and employees.
Pediatric dental is an Essential Health Benefit. When employees and their dependents enroll in the medical plan, members receive child dental
benefits as part of their medical coverage and not as a separate plan. Child dental benefits apply to all members under 19 years of age.
The employer is establishing this plan to provide medical and other benefits to its eligible employees and dependents. Employer acknowledges
that this plan constitutes an employee welfare benefit plan and agrees, as “sponsor,” to fully comply with the applicable provisions and
requirements of the Employee Retirement Income Security Act of 1974 (ERISA). Employer designates Health Plan and/or KPIC, as applicable,
as the fiduciary for claims and appeals arising under the Group Agreement and/or Group Policy, as applicable. Neither Health Plan nor KPIC is
the Plan Administrator of employer’s employee benefit plan as that term is defined under ERISA. This provision only applies to an employer who
sponsors an employee welfare benefit plan covered by ERISA, and where Health Plan’s and/or KPIC’s group health coverage is a component of
that employee welfare benefit plan.
I attest that my company meets the definition of “small employer” as defined by applicable federal and state law. I have a minimum of 1 W-2
employee (excluding the owner, spouse, or legal domestic partner) and attest that at least 50% of eligible employees are covered by group
coverage. Failure to maintain the participation requirements may result in non renewal of contract.
I understand that a Summary of Benefits and Coverage (SBC) for each of my medical plans is available at kp.org/smallbusiness-sbc/ga. I agree
to provide my eligible employees with SBCs for any plan(s) I have chosen or change to in the future.
Page 6 of 6
KFHP-KPIC-APP-GA-2019-1
Small Group 60990908 January 2019
Georgia Small Group
EMPLOYER APPLICATION
Business name (please print):
Any employees who are covered for health care under CHAMPUS/CHAMPVA, Medicare, Individual, or their spouse’s or parent’s group coverage
may waive health coverage. The participation calculation would apply to the remaining eligible employees. The employer will (1) maintain the
records necessary to the administration of the agreement; (2) report additions, changes, terminations, and other information necessary to the
administration of the agreement to Health Plan and/or KPIC, as applicable, within 30 days after the effective date of such additions, changes,
and terminations; (3) agree that if employer doesn’t notify Health Plan and/or KPIC, as applicable, of any insured ineligibility or termination within
30 days, shall forfeit any premium refund/credit that would otherwise have been due; (4) make all such records, including payroll records, tax
return, and personnel files and other documentation as determined by the Health Plan and/or KPIC, as applicable, available upon request to the
Health Plan and/or KPIC, as applicable, or its authorized representative; (5) pay all premiums in accordance with the terms of this agreement;
and (6) notify all employees of any termination or rescission of coverage which affects them and refund the appropriate contributions made by
the employee towards the premium.
All statements provided in this agreement are true, correct, complete, and within our personal knowledge. We understand and agree that this
agreement will become binding between Health Plan and/or KPIC, as applicable, and us only upon acceptance by Health Plan and/or KPIC, as
applicable. The absence of written approval won’t imply approval. Any intentional material misstatement or incomplete statement of fact will be
deemed a misrepresentation and may result in termination of all coverage with respect to us, our participating employees, and their dependents
without liability to Health Plan and/or KPIC, as permitted by applicable law.
Authorized company signer (please print name) Title (please print)
Signature required for all Kaiser Permanente Plans
X
Date
Page 1 of 5
Kaiser Foundation Health Plan of Georgia, Inc.
60900708 08/2018
Georgia Small Business
EMPLOYEE ENROLLMENT FORM
A EMPLOYEE INFORMATION
Last Name First Name MI Gender
M F
Date of Birth
/ /
Social Security Number
- -
E-mail Address Ethnicity (optional)
Address City State Zip Code
Home Phone Job Title Marital Status
Married Single Domestic Partner
Check if you are an existing or previous member. Please provide your Health Record Number.
Health Record Number or HRN#
Company Name Hours Worked Employment Status
Active COBRA
Are you an independent contractor?
Yes No
To be Completed by Employer
Effective Date
Group Number
Sub Group
Bill Group
/ /
(1-50 EMPLOYEES)
Kaiser Permanente Insurance Company (KPIC)
Language Preference
Check Plan Type:
KP/HDHP
Dual Choice PPO
Check Enrollment Type:
New Hire
Annual Enrollment
COBRA Enrollment
Waive Coverage
Fill Out Sections:
A, B, C, D
A, B, C, D
A, B, C, D
A, C, D
B COVERAGE STATUS Self Only Self + Spouse/DP Self + Child(ren) Self + Spouse + Child(ren)
SPOUSE/DOMESTIC PARTNER
Last Name First Name MI Check if existing member.
Date of Birth
/ /
Gender
M F
Social Security Number
- -
Health Record Number or HRN#
DEPENDENT 1
Last Name First Name MI Check if existing member.
Date of Birth
/ /
Gender
M F
Social Security Number
- -
Health Record Number or HRN#
Continued
Note: Please print and use blue or black ink
DEPENDENT 2
Last Name First Name MI Check if existing member.
Date of Birth
/ /
Gender
M F
Social Security Number
- -
Health Record Number or HRN#
Page 2 of 5
Kaiser Foundation Health Plan of Georgia, Inc.
60900708 08/2018
B COVERAGE STATUS CONTINUED
DEPENDENT 3
Last Name First Name MI Check if existing member.
Date of Birth
/ /
Gender
M F
Social Security Number
- -
Health Record Number or HRN#
C
WAIVER OF COVERAGE/OTHER COVERAGE INFORMATION
By completing this section, I acknowledge that I was given the opportunity to enroll in this plan of group health benefits offered by my employer.
I refuse the following:
All coverage Coverage for my spouse/DP Coverage for my children
Reason for refusal: (Please check all appropriate boxes)
Other group coverage sponsored by my employer
Other group coverage sponsored by my spouse’s/DP’s employer
Other group coverage sponsored by another organization
Individual coverage
Other reason (please explain)
Do you or any dependents have any other medical insurance? (check one) Yes No
Do you or any dependents currently receive Medicare benefits? (check one)
Yes No
Insurance Company Name Policy Number
Insurance Company Address City State Zip Code
Policy Holder Policy Holder Date of Birth
/ /
Georgia Small Business
EMPLOYEE ENROLLMENT FORM
D PLEASE SIGN APPLICATION
Please complete this application and submit it to your company’s Benefits Administrator. I understand and agree that if the application is accepted by
Kaiser Foundation Health Plan of Georgia, Inc. (“Health Plan”) and /or Kaiser Permanente Insurance Company (“KPIC”), as applicable, the benefits for which
I, and my dependents (if any) will be eligible will be in accordance with the Group Agreement and/or Group Policy, as applicable, to the type of plan for which
we are enrolled. I further understand and agree that I, and my dependents (if any) will be bound by the terms and conditions of such agreements. I authorize
the deduction from my wages, amounts necessary to pay the employee portion of the premiums for my, and my covered dependents’ (if any) Health Plan and/
or KPIC, as applicable, coverage. I understand that to be eligible for coverage and remain eligible, I must satisfy the eligibility requirements set forth in my
employer’s agreement with Health Plan, and that the information provided in this application may be relied on and used to determine my, and my dependents’
(if any) eligibility for such coverage.
I agree to provide any documentation, including tax returns, payroll records, etc. necessary to establish that I, and my dependents (if any) initially met and
continue to meet this or any other requirement for coverage. I understand that Health Plan will rely on the information set forth in the application and may take
any action allowed under applicable law if the statements are later found untrue, inaccurate or incomplete.
Continued
Page 3 of 5
Kaiser Foundation Health Plan of Georgia, Inc.
60900708 08/2018
Georgia Small Business
EMPLOYEE ENROLLMENT FORM
Dependent Eligibility Guidelines
1. To be a family dependent a person must be:
a. The subscriber’s spouse/DP (eligibility for a spouse ends at the end of the month in which a divorce is final or when a domestic partnership is dissolved).
b. Any child of the subscriber, including step child, adopted child, child placed for adoption, or foster child that is under the group’s age limit of 26 for
dependent status.
2. Dependent children incapable of self-sustaining employment may remain under the subscriber’s contract past the group’s age limit of 26 for dependent
status. Please complete a Coverage Request for Overage Dependent Children Form and attach it to this application.
If you have any questions concerning the benefits and services that are provided by or excluded under this agreement, please contact your Employer’s Human
Resources Department before signing this application.
Personal Information
In order to review your application, information may be collected from persons other than you and your covered family members. Information which is
collected may be disclosed to others without authorization only as allowed by law. Each covered person has a right to review and correct all personal
information which is collected about him. A more complete notice of our information practices is available upon request.
I authorize Kaiser Foundation Heath Plan of Georgia, Inc. (Health Plan) and Kaiser Permanente Insurance Company (KPIC) to use protected health information
(PHI) and history of care provided to me or my minor dependents.
I understand that Health Plan and KPIC may, without limitation and with respect to all categories of care review and use my PHI following my/our actual
enrollment and initial usage of services in order to confirm consistency with the information I submitted in this application or for such other purposes as
permitted by applicable federal and/or state laws or regulations. I understand that Health Plan and KPIC will not re-disclose any information received except
with my written consent, or as permitted by applicable federal and/or state laws or regulations. I understand that PHI disclosed to others may no longer be
protected by Kaiser Permanente policy or the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This authorization is effective for a period of
30 months from the date this application is signed. I understand that I may revoke this authorization in writing at any time, except to the extent that action has
been taken based on this authorization. I understand that revocation of an authorization used to secure a policy of insurance, including health coverage from
Kaiser Permanente, is not permitted during the period of time the insurer may contest the policy issued or a claim under the policy.
I further understand that to revoke this authorization I must send a written revocation notice signed by each individual over 18 years of age to: Kaiser
Foundation Heath Plan of Georgia, Inc., Nine Piedmont Center; 3495 Piedmont Road NE; Atlanta, Georgia 30305.
NOTICES:
1. I understand and agree that any intentional material misstatement or incomplete statement of fact provided on this application will be deemed to be an
intentional material misrepresentation and may result in the rescission of my coverage, as well as the coverage of my covered dependents (if any), without
liability to Health Plan and/or KPIC, as applicable. If coverage is rescinded, you may be billed for services received and we may use any premiums paid to
defray such costs.
2. This Plan has a network of participating physicians and other providers. My choice of physician or provider determines the level of benefits I receive.
Participating physicians and providers are subject to change. I can view a current list of Kaiser Permanente physicians at kp.org. Physicians and providers
are paid in a number of ways, including salary, capitation, case rates, fee for service, and incentive payments. I can get more information about how
participating physicians and providers are paid, request a Physician Directory, or obtain a list of current participating physicians and other providers by
calling Customer Service at 404-261-2590.
3. HMO plans (including HDHP plans) and the Kaiser Permanente Select Provider benefit level of the POS plans are provided by Kaiser Foundation Health
Plan of Georgia, Inc. The PPO Provider and Non-participating Provider benefit levels of the POS plans and Out-of-Area PPO plans are underwritten by
Kaiser Permanente Insurance Company
IMPORTANT: Please read the conditions above, and sign and date below. All applications MUST be signed in ink and dated by Primary
Applicant. I have read and understand all of the above conditions and terms. I certify that the answers given are true and complete.
Signature of Employee
X
Date
/ /
Page 4 of 5
Kaiser Foundation Health Plan of Georgia, Inc.
60900708 08/2018
NON-DISCRIMINATION
Kaiser Foundation Health Plan of Georgia, Inc. (Health Plan) and Kaiser Permanente Insurance Company,
Inc. (KPIC), individually and collectively, comply with applicable Federal civil rights laws and do not
discriminate on the basis of race, color, national origin, age, disability, or sex. Neither Health Plan nor
KPIC exclude people or treat them differently because of race, color, national origin, age, disability, or
sex. Health Plan and KPIC, as applicable, also:
Provide no cost aids and services to people with disabilities to communicate effectively with them, such as:
• Qualified sign language interpreters
• Written information in other formats, such as large print, audio, and accessible electronic formats
• Provide no cost language services to people whose primary language is not English, such as:
• Qualified interpreters
• Information written in other languages
If You need these services, call 1-888-865-5813 (TTY: 711)
If You believe that either Health Plan or KPIC has failed to provide these services or discriminated in
another way on the basis of race, color, national origin, age, disability, or sex, You can file a grievance by
mail at: Member Relations Unit (MRU), Attn: Kaiser Civil Rights Coordinator, Nine Piedmont Center,
3495 Piedmont Road, NE Atlanta, GA 30305-1736. Telephone Number: 1-888-865-5813.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services,
Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and
Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201,
1-800-368-1019, 1-800-537-7697 (TDD). Complaint forms are available at
http://www.hhs.gov/ocr/office/file/index.html.
Non-Discrimination
Kaiser Foundation Health Plan of Georgia, Inc. (Health Plan) and Kaiser Permanente Insurance Company, Inc. (KPIC), individually
and collectively, comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin,
age, disability, or sex. Neither Health Plan nor KPIC exclude people or treat them differently because of race, color, national origin,
age, disability, or sex. Health Plan and KPIC, as applicable, also:
Provide no cost aids and services to people with disabilities to communicate effectively with them, such as:
Qualified sign language interpreters
Written information in other formats, such as large print, audio, and accessible electronic formats
Provide no cost language services to people whose primary language is not English, such as:
Qualified interpreters
Information written in other languages
If You need these services, call 1-888-865-5813 (TTY: 711)
If You believe that either Health Plan or KPIC has failed to provide these services or discriminated in another way on the basis of
race, color, national origin, age, disability, or sex, You can file a grievance by mail at: Member Relations Unit (MRU), Attn: Kaiser
Civil Rights Coordinator, Nine Piedmont Center, 3495 Piedmont Road, NE Atlanta, GA 30305-1736. Telephone Number: 1-888-865-
5813.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electroni-
cally through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf,
or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building,
Washington, DC 20201, 1-800-368-1019, 1-800-537-7697 (TDD). Complaint forms are available at
http://www.hhs.gov/ocr/office/file/index.html.
Help in Your Language
ATTENTION: If You speak English, language assistance services, free of charge, are available to You. Call 1-888-865-5813 (TTY:
711).
ማርኛ (Amharic) ስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነ ሊያግዝዎት ተዘጋጀተዋል ወደ ሚከተለ ቁጥር ይደውሉ 1-888-
865-5813 (TTY: 711).
(Arabic) TTY1-888-865-5813
(Chinese) 注意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致1-888-865-5813TTY711)。
(Farsi) 5813 (711 :TTY) 1-888-865-

Français (French) ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le
1-888-865-5813 (TTY: 711).
Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur
Verfügung.
Rufnummer: 1-888-865-5813 (TTY: 711).
ગજ
રાતી (Gujarati)
ચના:  
  ,  :
       .   1-888-865-
5813 (TTY: 711).
Kreyòl Ayisyen (Haitian Creole) ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-
888-865-5813 (TTY: 711).
हिदी (Hindi) यान द: यदि आप
िी बोलते तो के दलए
त म भाषा स ायता सेवाए
उपलध । 1-888-865-5813 (TTY: 711) पर कॉल कर
Page 5 of 5
©2018 Kaiser Foundation Health Plan of Georgia, Inc.
Nine Piedmont Center • 3495 Piedmont Road, NE
Atlanta, GA 30305 • 404-364-7000
Small Business 60900708 07/2018
Non-Discrimination
Kaiser Foundation Health Plan of Georgia, Inc. (Health Plan) and Kaiser Permanente Insurance Company, Inc. (KPIC), individually
and collectively, comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin,
age, disability, or sex. Neither Health Plan nor KPIC exclude people or treat them differently because of race, color, national origin,
age, disability, or sex. Health Plan and KPIC, as applicable, also:
Provide no cost aids and services to people with disabilities to communicate effectively with them, such as:
Qualified sign language interpreters
Written information in other formats, such as large print, audio, and accessible electronic formats
Provide no cost language services to people whose primary language is not English, such as:
Qualified interpreters
Information written in other languages
If You need these services, call 1-888-865-5813 (TTY: 711)
If You believe that either Health Plan or KPIC has failed to provide these services or discriminated in another way on the basis of
race, color, national origin, age, disability, or sex, You can file a grievance by mail at: Member Relations Unit (MRU), Attn: Kaiser
Civil Rights Coordinator, Nine Piedmont Center, 3495 Piedmont Road, NE Atlanta, GA 30305-1736. Telephone Number: 1-888-865-
5813.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electroni-
cally through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf,
or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building,
Washington, DC 20201, 1-800-368-1019, 1-800-537-7697 (TDD). Complaint forms are available at
http://www.hhs.gov/ocr/office/file/index.html.
Help in Your Language
ATTENTION: If You speak English, language assistance services, free of charge, are available to You. Call 1-888-865-5813 (TTY:
711).
አማርኛ (Amharic) ስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል ወደ ሚከተለው ቁጥር ይደውሉ 1-888-
865-5813 (TTY: 711).
(Arabic) TTY1-888-865-5813
中文 (Chinese) 注意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致電1-888-865-5813TTY711)。
(Farsi) 5813 (711 :TTY) 1-888-865-

Français (French) ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le
1-888-865-5813 (TTY: 711).
Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur
Verfügung.
Rufnummer: 1-888-865-5813 (TTY: 711).
ગજ
રાતી (Gujarati)
ચના:  
  ,  :
       .   1-888-865-
5813 (TTY: 711).
Kreyòl Ayisyen (Haitian Creole) ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-
888-865-5813 (TTY: 711).
हिदी (Hindi) यान द: यदि आप
िी बोलते तो के दलए
त म भाषा स ायता सेवा
उपलध । 1-888-865-5813 (TTY: 711) पर कॉल कर
日本語 (Japanese) 注意事項:日本語を話される場合、無料の言語支援をご利用いただけます。1-888-865-5813TTY:
711)まで、お電話にてご連絡ください。
국어 (Korean) 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료 이용하실 있습니다. 1-888-865-5813 (TTY:
711) 번으로 전화해 주십시오.
Naabeehó (Navajo) Díí baa akó nínízin: Díí saad bee yáníłti’go Diné Bizaad, saad bee áká’ánída’áwo’dé
̖
é
̖
’, t’áá jiik’eh, éí ná hóló
̖
,
koji
̖
’ hódíílnih 1-888-865-5813 (TTY: 711).
Português (Portuguese) ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-888-
865-5813 (TTY: 711).
Pусский (Russian) ВНИМАНИЕ: eсли вы говорите на русском языке, то вам доступны бесплатные услуги перевода.
Звоните 1-888-865-5813 (TTY: 711).
Español (Spanish) ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-888-
865-5813 (TTY: 711).
Tagalog (Tagalog) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang
walang bayad.
Tumawag sa 1-888-865-5813 (TTY: 711).
Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-888-865-
5813 (TTY: 711).
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