Fillable Community Health Access Program Account Change Form (Kaiser Permanente)

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Community Health Access Program Account Change Form (Kaiser Permanente)

On average this form takes 47 minutes to complete

The Community Health Access Program Account Change Form (Kaiser Permanente) form is 7 pages long and contains:

  • 6 signatures
  • 1 check-box
  • 163 other fields

Country of origin: US
File type: PDF

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Page 1 of 7
815348722 VA 2022
Community Health Access Program
Account Change Form
When to use this form
Use this form to make changes to your Kaiser Permanente Community Health Access Program account, which provides help in
paying your health plan premiums and most out-of-pocket costs. This form is not for applying for coverage in Kaiser Permanente’s
VA Gold 0/20/Vision plan.
How to complete and submit this form
Please complete all sections that apply to your change, type or print using black or blue ink. See the table below for sections that
need to be completed. Be sure to sign and date the form.
Not all changes need to be made using this form. Some changes can be made by phone. To make changes by phone, please call
Member Services at 1-800-777-7902 (TTY 711), Monday through Friday, 7:30 a.m. to 9:00 p.m. Eastern time (closed major holidays)
Type of change Complete the following sections Submit the form
Update my contact information A, B, H
Or call to request the change
Email, fax, or mail the completed form
Change a name
A, C, H
Email, fax, or mail the completed form
and any supporting documentation
(such as a driver’s license, marriage
certificate, or divorce decree)
Remove a dependent A, D, H
Or call to request the change
Email, fax, or mail the completed form
Cancel membership for everyone on
the account
A, E, H
Or call to request the change
Email, fax, or mail the completed form
Add a dependent A, F, H Email, fax, or mail the completed
form and any required supporting
documentation
Change the parent/legal guardian of a
covered dependent
A, G, H Email, fax, or mail the completed form
and any supporting documentation of
guardianship (such as a court order)
Contact information
Email to:
CHC-Applications@kp.org
Fax toll-free to:
1-855-355-5334
Mail to:
California Service Center
Attn: CHC
P.O. Box 939095
San Diego, CA 92193-9095
Questions?
We’re here to help. Call
1-800-777-7902 (TTY 711)
Monday through Friday, 7:30 a.m. to
9:00 p.m. Eastern time (closed major
holidays).
Page 2 of 7
815348722 VA 2022
Community Health Access Program
Account Change Form
Virginia
A. Fill out your information
Please select one: I’m the
primary member (must be 18 or older) parent/guardian (if primary member is under 18)
First name MI
Last name
Medical record number (if any) Date of birth (mm/dd/yyyy) Gender:
Male Female
Written language preference Spoken language preference
B. Update contact information
Fill out any information that’s changed.
Mailing address (Include Apt. Number. P.O. boxes acceptable)
City State ZIP code
Home address, if different from mailing address (Include Apt. Number. No P.O. boxes, please)
City State ZIP code
Email (optional) I understand I may be contacted via email.
Home phone Mobile phone
- -
- -
Page 3 of 7
815348722 VA 2022
C. Change a name
Whose name is changing?
Child
Spouse Primary member
Old name
First name
MI
Last name
New name
First name
MI
Last name
D. Remove a dependent from my account
If you’re removing more than 2 dependents, make a copy of this page before filling it out and attach it with the form.
Dependent 1
First name
MI
Last name
Medical record number
Date of birth (mm/dd/yyyy)
What month do you want this change to start? The earliest a change can start is the first of the month after we receive your request.
(mm/yyyy)
Dependent 2
First name
MI
Last name
Medical record number
Date of birth (mm/dd/yyyy)
What month do you want this change to start? The earliest a change can start is the first of the month after we receive your request.
(mm/yyyy)
E. Cancel membership for everyone on the account
Please cancel membership in the Kaiser Permanente Community Health Access Program for everyone on this account. I
understand that this will cancel enrollment in the Kaiser Permanente VA Gold 0/20/Vision plan for everyone on this account.
What month do you want this change to start? The earliest a change can start is the first of the month after we receive your request.
(mm/yyyy)
Page 4 of 7
815348722 VA 2022
F. Add a dependent
The Kaiser Permanente Community Health Access Program provides a subsidy to help pay your monthly premiums and most
out-of-pocket medical costs under your current Kaiser Permanente plan.
Your dependent(s) may qualify for the Kaiser Permanente Community Health Access Program if they do not currently have health
coverage and:
•
Live in the Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. service area, excluding the District of Columbia
•
Live in a household with an income up to 300% of the federal poverty level
•
Can’t be eligible for other public or private health coverage such as, but not limited to, Medicaid, FAMIS, Medicare, a job-based
health plan, or financial help through the health benefit exchange.
These rules are subject to change. Visit kp.org/mas-chap for the latest requirements.
If you’re adding a dependent outside of the open enrollment period, you must have had a qualifying life event. For a complete list
of qualifying life events, please visit kp.org/chcspecialenrollment or call 1-800-777-7902 (TTY 711) for more information.
Choose the life event that made your dependent eligible for a special enrollment period:
Loss of minimum essential health coverage (write the last
full day your dependent had coverage)*
Gaining or becoming a dependent through marriage
Gaining or becoming a dependent through the birth of a child,
adoption, or placement for adoption or foster care
Note:
In this case, you also need to choose between 2 effective
date options:
The date of birth, adoption, or placement for adoption or
foster care
The first day of the month after the birth or placement of
the child with you
Permanent relocation with access to new plans
Child support order or other court order to cover
a dependent
Note: In this case, you also need to choose between
2 effective date options:
The date of the child support order or other
court order to cover a dependent
The first day of the month after the court
order date
Determination by the health benefit exchange of
exceptional circumstances
Please write the date of your qualifying life event.
(mm/dd/yyyy)
*If your qualifying life event is loss of Kaiser Permanente coverage, we may review your prior membership records to verify loss of
minimum essential coverage.
Proof of your qualifying life event is required.
•
For loss of health care coverage, attach proof, such as a letter from your employer, letter from your insurer, or Medicaid,
Medi-Cal, Medicare, or other government programs stating when your dependent’s minimum essential coverage ended
or will end.
•
For examples of required proof of other qualifying life events, please visit kp.org/chcspecialenrollment or call
1-800-777-7902 (TTY 711).
(continues)
Page 5 of 7
815348722 VA 2022
F. Add a dependent
(continued)
Please complete the information below. If you’re adding more than 2 dependents, attach another form and complete just the
information for those dependents.
Dependent 1
First name MI Last name
Social Security number (optional) Medical record number Date of birth (mm/dd/yyyy)
-
-
Gender:
Male
Female
Relationship to primary member:
Spouse
Child/Dependent
If Dependent 1 is 21 and older: Has Dependent 1 used tobacco at least 4 times per week in the past 6 months (except for
religious/ceremonial use)? Products include cigarettes, cigars, and chewing/smokeless tobacco. Regular tobacco users may
pay different premiums.
Yes No
Is Dependent 1 ...
A U.S. citizen?
Yes No
A legal permanent resident?
Yes No
If yes, how many years has the dependent been a legal permanent resident?
Does your job offer health coverage for this dependent?
Yes No
What month do you want Dependent 1’s coverage to start? The earliest a change can start is the first of the month after we receive
your request.
(mm/yyyy)
Dependent 2
First name
MI Last name
Social Security number (optional) Medical record number Date of birth (mm/dd/yyyy)
-
-
Gender:
Male
Female
Relationship to primary member:
Spouse
Child/Dependent
If Dependent 2 is 21 and older: Has Dependent 2 used tobacco at least 4 times per week in the past 6 months (except for
religious/ceremonial use)? Products include cigarettes, cigars, and chewing/smokeless tobacco. Regular tobacco users may
pay different premiums.
Yes No
Is Dependent 2 ...
A U.S. citizen?
Yes No
A legal permanent resident?
Yes No
If yes, how many years has the dependent been a legal permanent resident?
Does your job offer health coverage for this dependent?
Yes No
What month do you want Dependent 2’s coverage to start? The earliest a change can start is the first of the month after we receive
your request.
(mm/yyyy)
Page 6 of 7
815348722 VA 2022
G. Change parent/legal guardian of a covered dependent
The new parent or legal guardian must be 18 or older and financially responsible for the covered dependent. You must include
documentation of guardianship with your form.
Current parent or legal guardian
First name
MI
Last name
X
Signature of current parent or legal guardian
Date (mm/dd/yyyy)
New parent or legal guardian
First name
MI
Last name
X
Signature of new parent or legal guardian
Date (mm/dd/yyyy)
Information about the new parent or legal guardian:
Date of birth (mm/dd/yyyy)
Social Security number (optional)
-
-
Phone
-
-
Gender:
Male Female
Relationship to primary member:
Parent
Legal guardian
Marital status:
Single Married Domestic partner Divorced Separated Widowed
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Page 7 of 7
815348722 VA 2022
H. Signature
By signing this form, you certify the information on this form is correct and accurate. If you provide any incorrect or incomplete
information or in further correspondence concerning this form, any Kaiser Permanente subsidy to cover costs related to health
coverage may be terminated. Membership approval for Kaiser Permanente’s Community Health Access Program is not guaranteed
as it is based on eligibility and availability.
X
Required signature (primary member or parent/legal guardian for applicants under 18)
Date (mm/dd/yyyy)
X
Required signature of primary member (18 and older)
Date (mm/dd/yyyy)
X
Required signature of current parent/legal guardian (if primary member is under 18)
Date (mm/dd/yyyy)
X
Required signature of new adult dependent (18 and older)
Date (mm/dd/yyyy)
All plans are offered and underwritten by Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc., 2101 East Jefferson St., Rockville, MD 20852.
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60577108_ACA_1557_MarCom_MAS_2017_Taglines
NONDISCRIMINATION NOTICE
Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. (Kaiser Health Plan)
complies with applicable federal civil rights laws and does not discriminate on the
basis of race, color, national origin, age, disability, or sex. Kaiser Health Plan does
not exclude people or treat them differently because of race, color, national origin,
age, disability, or sex. We also:
• Pr
ovide no cost aids and services to people with disabilities to communicate
effectively with us, such as:
• Qualified sign language interpreters
• Written information in other formats, such as large print, audio, and
accessible electronic formats
• Pr
ovide 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 1-800-777-7902 (TTY: 711)
If you believe that Kaiser Health Plan 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 or phone at: Kaiser Permanente, Appeals and
Correspondence Department, Attn: Kaiser Civil Rights Coordinator, 2101 East
Jefferson St., Rockville, MD 20852, telephone number: 1-800-777-7902.
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.
In the event of dispute, the provisions of the approved English version of the form will
control.
____________________________________________________________________
HELP IN YOUR LANGUAGE
ATTENTION: If you speak English, language assistance services, free of charge, are
available to you. Call 1-800-777-7902 (TTY: 711).
አአማርኛ (Amharic) ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት
ተዘጋጀተዋል ወደ ሚከተለው ቁጥር ይደውሉ 1-800-777-7902 (TTY: 711).
 (Arabic) :العيبرة
1-800-777-7902TTY
Ɓasɔɔ Wuɖu (Bassa) Dè ɖɛ nìà kɛ dyéɖé gbo: Ɔ jǔ ké m Ɓàsɔɔ-wùɖù-po-nyɔ jǔ ní,
nìí, à wuɖu kà kò ɖò po-poɔ ɓɛìn m gbo kpáa. Ɖá 1-800-777-7902 (TTY: 711)
̌
́ ̀ ̀ ̀ ̀ ́ ̀ ̀
̀ ́ ̀
(Bengali) , , 
1-800-777-7902 (TTY: 711)
中中文文 (Chinese) 注注意意：：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
1-800-777-7902（TTY：711）。
ማርኛ ማስታወሻ
:

 
日
本語 注意事項：
한국어 주의:
 (Farsi)      

1-800-777-7902( TTY : 711 )
 
Français (French) ATTENTION: Si vous parlez français, des services d'aide linguistique
vous sont proposés gratuitement. Appelez le 1-800-777-7902 (TTY: 711).
Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos
sprachliche Hilfsdienstleistungen zur Verfügung.
Rufnummer: 1-800-777-7902 (TTY: 711).


(Gujarati)
:
  
  , :   
 
 .   1-800-777-7902 (TTY: 711).
Kreyòl A
yisyen (Haitian Creole) ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd
pou lang ki disponib gratis pou ou. Rele 1-800-777-7902 (TTY: 711).

(Hindi)

:              
 1-800-777-7902 (TTY: 711)   
Igbo (Igbo) NRỤBAMA: Ọ bụrụ na ị na asụ Igbo, ọrụ enyemaka asụsụ, n’efu, dịịrị gị.
Kpọọ 1-800-777-7902 (TTY: 711).
Italiano (Italian) ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili
servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-777-7902 (TTY: 711).
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。1-800-777-7902（TTY: 711）まで、お電話にてご連絡ください。
한국어
(Korean)
주의:
한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실
수 있습니다. 1-800-777-7902 (TTY: 711) 번으로 전화해 주십시오.
Naabeehó (Navaj
̖̖
o) Díí baa akó nínízin: Díí saad bee yáníłti’go Diné Bizaad, saad bee
áká’ánída’áwo’déé’, t’áá jiik’eh, éí ná hóló
̖
, koj
̖
i’ hódíílnih 1-800-777-7902 (TTY: 711).
Português (Portuguese) ATENÇÃO: Se fala português, encontram-se disponíveis
serviços linguísticos, grátis. Ligue para 1-800-777-7902 (TTY: 711).
Pусский (Russian) ВНИМАНИЕ: eсли вы говорите на русском языке, то вам
доступны бесплатные услуги перевода. Звоните 1-800-777-7902 (TTY: 711).
Español (Spanish) ATENCIÓN: si habla español, tiene a su disposición servicios
gratuitos de asistencia lingüística. Llame al 1-800-777-7902 (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 1-800-777-7902 (TTY: 711).
ไทย (Thai) เร ียน: ถ ้าคุณพูดภาษาไทย คุณสามารถใช
้
บริการช
่
วยเหลือทางภาษาได้ฟร ี โทร
1-800-777-7902 (TTY: 711).
(Urdu)          

1-800-777-7902
( 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 1-800-777-7902 (TTY: 711).
Yorùbá (Yoruba) AKIYESI: Ti o ba nso ede Yoruba ofe ni iranlowo lori ede wa fun yin
o. E pe ero ibanisoro yi 1-800-777-7902 (TTY: 711).
60577108_ACA_1557_MarCom_MAS_2017_Taglines
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Community Health Access Program Account Change Form (Kaiser Permanente)

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