Fillable EMPLOYEE ENROLLMENT Small Business COMPANY & PLAN INFORMATION

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EMPLOYEE ENROLLMENT Small Business COMPANY & PLAN INFORMATION

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  • 5 check-boxes
  • 88 other fields

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Small Business
718148050 January 2022 ADA
Small Business
EMPLOYEE ENROLLMENT
Use this form to enroll in Kaiser Permanente. (All fields with * are required.)
COMPANY & PLAN INFORMATION
Company name* Group ID (if assigned) Effective date* (can only start the first of the month)
/ 01 /
Plan selection* Subgroup ID (if assigned) Employee classification (if applicable)
Enrollment reason (Please check one) New group account Open enrollment Other:
If you have an existing account, please email completed form to csc-sd-sba@kp.org as a PDF attachment or fax to 855-355-5334.
EMPLOYEE INFORMATION
Have you ever been a member of, or received care from, Kaiser Permanente in California? Yes No
Social Security number* Former/Maiden name
Last name* First name* MI Preferred language (optional)
Home address* Apt. #
City* State* ZIP* County
Mailing address (if different from home) Apt. #
City State ZIP County
Date of birth (mm/dd/yyyy)*
/
Gender*
M F Undeclared
Day phone
( –
Evening phone
(
If you decline coverage for yourself or an eligible dependent, you can only enroll during an annual open enrollment period established by your employer, or during
a special enrollment period if you’ve experienced a qualifying event. You must request coverage within 60 days of a qualifying event. Special enrollment qualifying
events include:
•
Loss of health care (minimal essential) coverage, resulting from any of the following: loss of employer-sponsored coverage because you and/or your dependent
no longer meet the eligibility requirements, or your employer no longer offers coverage or stops contributing premium payments; loss of eligibility for COBRA
coverage (for a reason other than termination for cause or nonpayment of premium); your and/or your dependent’s individual, Medi-Cal, Medicare, or other
governmental coverage ends; or for any reason other than failure to pay premiums on a timely basis or situations allowing for a rescission (fraud or intentional
misrepresentation of material fact); or loss of health care coverage including, but not limited to, loss of that coverage due to the circumstances described in
Section 54.9801-6(a)(3)(i) to (iii), inclusive, of Title 26 of the Code of Federal Regulations and the circumstances described in Section 1163 of Title 29 of the
United States Code;
•
Gaining or becoming a dependent due to marriage, domestic partnership, birth, adoption, placement for adoption, or assumption of a parent-child relationship;
•
A valid state or federal court order that you or your dependent be covered;
•
Permanent relocation, such as moving to a new location and having a different choice of health plans, or being released from incarceration;
•
The prior health coverage issuer substantially violated a material provision of the health coverage contract;
•
A network provider’s participation in your and/or your dependent’s health plan ended when you and/or your dependent(s) were under active care for one of the
following conditions: an acute condition (an acute condition is a medical condition that involves a sudden onset of symptoms due to an illness, injury, or other
medical problem that requires prompt medical attention and that has a limited duration); a serious chronic condition (a serious chronic condition is a medical
condition due to a disease, illness, or other medical problem or medical disorder that’s serious in nature and that persists without full cure or worsens over
an extended period of time or requires ongoing treatment to maintain remission or prevent deterioration); pregnancy; terminal illness (a terminal illness is an
incurable or irreversible condition that has a high probability of causing death within one year or less); care of a newborn child between birth and age 36 months;
or performance of a surgery or other procedure that’s been recommended and documented by the provider to occur within 180 days of the contract’s termination
date or within 180 days of the effective date of coverage for a newly covered insured;
•
A member of the reserve forces of the United States military returning from active duty or a member of the California National Guard returning from active duty
service under Title 32 of the United States Code;
•
An individual demonstrates to the Department of Managed Health Care or Department of Insurance, as applicable, with respect to health benefit plans offered
outside the Exchange that the individual didn’t enroll in a health benefit plan during the immediately preceding enrollment period available because the individual
was misinformed that he or she was covered under minimum essential coverage.
(All fields with * are required.)
) ) –
/
Email completed form to csc-sd-sba@kp.org or fax to 855-355-5334.
Small Business
718148050 January 2022 ADA
Small Business
EMPLOYEE ENROLLMENT
FAMILY INFORMATION (Please list only those family members to be enrolled.)
Check one
Spouse Domestic partner
Date of birth (mm/dd/yyyy)* Gender* M F
Undeclared
Social Security number
Name (Last, First, MI)*
Former name (Last, First, MI)
Dependent*
Date of birth (mm/dd/yyyy)* Gender* M F
Undeclared
Social Security number
Name (Last, First, MI)
Dependent*
Date of birth (mm/dd/yyyy)* Gender* M F
Undeclared
Social Security number
Name (Last, First, MI)
Dependent*
Date of birth (mm/dd/yyyy)* Gender* M F
Undeclared
Social Security number
Name (Last, First, MI)
Dependent*
Date of birth (mm/dd/yyyy)* Gender* M F
Undeclared
Social Security number
Name (Last, First, MI)
Dependent*
Date of birth (mm/dd/yyyy)* Gender* M F
Undeclared
Social Security number
Name (Last, First, MI)
If any dependent listed above lives at another address, complete the following:
Name (Last, First, MI) Address
Name (Last, First, MI) Address
READ AND SIGN
KAISER FOUNDATION HEAL
TH PLAN, INC., 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 can’t 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 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 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.
Employee name (please print)*
Employee signature* Date
(All fields with * are required.)
†
Disputes arising from fully insured Kaiser Permanente Insurance Company (KPIC) coverage aren’t subject to binding arbitration: 1) Preferred Provider Organization (PPO) plans and 2)
KPIC Dental plans.
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EMPLOYEE ENROLLMENT Small Business COMPANY & PLAN INFORMATION

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Completed 25 October 2021

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