Do any of dependents above live at another address? Yes No If yes, complete the
follo
w
i
n
g:
California Region Kaiser Permanente Group Enrollment Form
Please print
or
type
in
black ink only. Make a copy for your
records.
TO BE COMPLETED BY EMPLOYER:
cal Group
Number
:
rollment
Unit:
Effective Enr
oll
men
t Date
(
mm
/
dd
/
yyy
y)
Complete this section ONLY if dental, vision and/or life insurance is offered through SISC:
Delta
Dental
Group#:
Vis
i
on
Group#:
SISC
Life
Ins
Group#:
Emp
l
oyee
Only
A. ENROLLMENT: 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
Loss
of Other Coverage (complete sections A, B, C, D) Other (please specify)
Event
Date (mm/dd/yyyy)
B. EMPLOYEE: Have you ever been a Kaiser Permanente member? Yes No
Medical
Record
No. (if known)
C. FAMILY For additional dependents attach a separate sheet with employee’s name at top.
(Last,
First, MI)
Add Spouse Domestic partner Med Den Vision
S
p
o
u
s
e
/
d
o
me
s
t
i
c
SDUWQHUQDPH
Gender: Male Female
Social Security
No
.
Birth Date
(
mm
/
dd
/
yyyy
)
Add Son Daughter
Med Den Vision
Dependent name:
Social Security
No
.
Birth Date
(
mm
/
dd
/
yyyy
)
Add Son Daughter Med Den Vision
Dependent name:
Social Security
No
.
Birth Date
(
mm
/
dd
/
yyyy
)
Add Son Daughter Med Den Vision
Dependent name:
Social Security
No
.
Birth Date
(
mm
/
dd
/
yyyy
)
D. K
aiser Foundation Health Plan Arbitration Agreement
I understand that (except for Small Claims Court cases, claims subject to a Medicare appeals procedure or the ERISA claims procedure
regulation, and any other claims that cannot be subject to binding arbitration under governing law) any dispute between myself, my heirs,
relatives, or other associated parties on the one hand and Kaiser Foundation Health Plan, Inc. (KFHP), 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, 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 de
cided by binding arbitr
ation 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.
S
ig
n
a
t
u
r
e
required
for
all Kaiser
P
e
r
m
a
nen
t
e
Plans Date
(Excluding KPIC PPO, KPIC
OOA,
and KPIC
D
en
t
a
l
P
l
a
n
s
)
*
D
i
s
p
u
t
e
s
arising
from
fully-insured Kaiser Permanente Insurance Company (KPIC) coverage are not subject to binding arbitration1) the Preferred Provider Organization (PPO)
and
the
Out-of Network portion of the Point of Service (POS) plans; 2) Preferred Provider Organization (PPO) plans; 3) Out of Area Indemnity (OOA) plans; and 4) KPIC Dental
plans.
79
829
Revision
date 5/02/2016 SISC
click to sign
signature
click to edit
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