Fill - Free fillable Election form Group Plan Northern California or Southern (College of Alameda) PDF form

Group Plan

Kaiser Permanente Senior Advantage (HMO)

Election form

Northern California or Southern California Region Group Plan

Filling out and returning the enrollment form is your ﬁrst step to becoming a Kaiser Permanente

Senior Advantage member. If you and your spouse are both applying, you’ll each need to ﬁll out a

separate form. For help completing the enrollment form, call our Member Services Contact Center

at 1-800-443-0815 (TTY 711), seven days a week, 8 a.m. to 8 p.m.

How to ﬁll out this form

1. Answer all questions and print your answers using black or blue ink. Fill in check boxes

with an X.

2. Sign the form on page 5 and date it. Make sure you’ve read all the pages before you sign.

3. Mail the original, signed form to:

Kaiser Permanente – Medicare Unit

P.O. Box 232400

San Diego, CA 92193-2400

4. Make a copy for your records. If required, submit a copy to your employer group, union

or trust fund.

Next steps

• We’ll review your form to make sure it’s complete. Then we’ll let you know by mail that

we’ve received it.

• We’ll let Medicare know that you’ve applied for Senior Advantage.

• Within 10 calendar days after Medicare conﬁrms your enrollment, we’ll ﬁrst let you know the start

date for your coverage. Next, we will send you a Kaiser Permanente ID card and your new

member package within 10 days of your start date.

To check on the status of your application, please visit kp.org/medicare/applicationstatus.

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Employer Group Use Only

Please provide receipt date of form in this section when submitting on behalf of employee/retiree.

Employer Group #:

Employer Receipt Date:

Authorized Rep:

Please contact Kaiser Permanente if you need information in another language or accessible format (Braille).

To Enroll in Kaiser Permanente Senior Advantage, Please Provide the Following Information

Employer or Union Name: Group #:

LAST Name:

FIRST Name: Middle Initial: Gender:

Male Female

Are you a current or former member of any Kaiser Permanente

health plan? Yes No If yes: Current Former

Kaiser Permanente Medical/Health Record Number:

Permanent Residence Street Address (P.O. Box is not allowed):

City:

County: State: ZIP Code:

Home Phone Number: Mobile Phone Number: Birth Date: (mm/dd/yyyy)

- - - -

/ /

Mailing Address (only if different from your Permanent Residence Address)

Street Address:

City: State: ZIP Code:

E-mail Address:

Page 1 of 5

/ /

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NCAL or SCAL - Senior Advantage - Group Page 2 of 5

Last Name

First Name

Please Provide Your Medicare Insurance Information

Please take out your red, white and blue Medicare card to

complete this section.

• Fill out this information as it appears on your

Medicare card.

- OR -

• Attach a copy of your Medicare card or your letter from

Social Security or the Railroad Retirement Board.

Name (as it appears on your Medicare card):

Medicare Number:

Is Entitled To: Effective Date:

HOSPITAL (Part A)

MEDICAL (Part B)

You must have Medicare Part B, however most employer groups

require both Parts A and B to join a Medicare Advantage plan.

Please Read and Answer These Important Questions

1. Do you or your spouse work? Yes No

2. Are you the retiree? Yes No

If yes, retirement date (mm/dd/yyyy):

/ /

If no, name of retiree:

3. Are you covering a spouse or dependents under this employer or union plan? Yes No

If yes, name of spouse:

Name(s) of dependent(s):

4. Some individuals may have other drug coverage, including other private insurance, Worker’s Compensation, VA beneﬁts, or

State pharmaceutical assistance programs.

Will you have other prescription drug coverage in addition to Kaiser Permanente? Yes No

If yes, please list your other coverage and your identiﬁcation (ID) number(s) for that coverage.

Name of other coverage: ID # for other coverage:

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/ /

NCAL or SCAL - Senior Advantage - Group Page 3 of 5

Last Name First Name

5. Are you a resident in a long-term care facility, such as a nursing home? Yes No

If yes, please provide the following information:

Name of institution:

Address of institution (number and street): Phone Number:

- -

6. Requested effective date (subject to CMS approval):

/ /

Please check one of the boxes below if you would prefer that we send you information in a language other than English

or in an accessible format:

Spanish Large Print Braille CD

Please contact Kaiser Permanente at 1-800-443-0815 if you need information in an accessible format or language other than what

is listed above. Our ofﬁce hours are seven days a week, 8 a.m. to 8 p.m. TTY users should call 711.

Please complete the information below

If you currently have Kaiser Permanente coverage through more than one employer or union/trust fund, you must choose ONE

employer or union/trust fund from which to receive your Senior Advantage coverage. Complete the information for that employer

or union/trust fund below.

Employer Group/Union/Trust Fund Name:

Employer Group/Union/Trust Fund ID #: Subgroup: Requested effective date (subject to CMS approval):

/ /

Please Read and Sign Below

By completing this enrollment application, I agree to the following:

Kaiser Permanente is a Medicare Advantage plan and has a contract with the Federal government. I will need to keep my

Medicare Part B, however most employer groups require both Parts A and B. I can only be in one Medicare Advantage plan at a

time and I understand that my enrollment in this plan will automatically end my enrollment in another Medicare health plan. It

is my responsibility to inform you of any prescription drug coverage that I have or may get in the future. I understand that if I

don’t have Medicare prescription drug coverage, or creditable prescription drug coverage (as good as Medicare’s), I may have to

pay a late enrollment penalty if I enroll in Medicare prescription drug coverage in the future. I may leave this plan at any time by

sending a request to Kaiser Permanente or by calling 1-800-MEDICARE (1-800-633-4227 or TTY 1-877-486-2048), 24 hours a

day, 7 days a week. However, before I request disenrollment, I will check with my group or union/trust fund to determine if I am

able to continue my group membership.

I understand that if I currently have Kaiser Permanente coverage through more than one employer or union/trust fund, I must

choose one of these coverage options for my Senior Advantage plan because I can be enrolled in only one Senior Advantage plan

at a time. My other employer or union/trust fund may allow me to enroll in one of their non-Medicare plans as well. I will contact

the beneﬁt administrators at each of my employers or union/trust funds to understand the coverage that I am entitled to before I

make a decision about which employer’s or union/trust fund’s plan to select for my Senior Advantage plan.

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Last Name

First Name

Kaiser Permanente serves a speciﬁc service area. If I move out of the area that Kaiser Permanente serves, I need to notify the

plan so I can disenroll and ﬁnd a new plan in my new area. Once I am a member of Kaiser Permanente, I have the right to appeal

plan decisions about payment or services if I disagree. I will read the Senior Advantage Evidence of Coverage document from

Kaiser Permanente when I receive it in order to know which rules I must follow to get coverage with this Medicare Advantage

plan. I understand that people with Medicare aren’t usually covered under Medicare while out of the country except for limited

coverage near the U.S. border.

I understand that beginning on the date Senior Advantage coverage begins, I must get all of my health care from

Kaiser Permanente, except for emergency or urgently needed services or out-of-area dialysis services.

Services authorized by Kaiser Permanente and other services contained in my Senior Advantage Evidence of Coverage

document (also known as a member contract or subscriber agreement) will be covered. Without authorization, NEITHER

MEDICARE NOR KAISER PERMANENTE WILL PAY FOR THE SERVICES.

I understand that if I am getting assistance from a sales agent, broker, or other individual employed by or contracted with

Kaiser Permanente, he/she may be paid based on my enrollment in Kaiser Permanente.

Release of Information

By joining this Medicare health plan, I acknowledge that the Medicare health plan will release my information to Medicare

and other plans as necessary for treatment, payment and health care operations. I also acknowledge that Kaiser Permanente

will release my information including my prescription drug event data to Medicare, who may release it for research and other

purposes which follow all applicable Federal statutes and regulations. The information on this enrollment form is correct to

the best of my knowledge. I understand that if I intentionally provide false information on this form, I will be disenrolled from

the plan.

I understand that my signature (or the signature of the person authorized to act on my behalf under the laws of the State where

I live) on this application means that I have read and understand the contents of this application. If signed by an authorized

individual (as described above), this signature certiﬁes that: 1) this person is authorized under State law to complete this

enrollment and 2) documentation of this authority is available upon request from Medicare.

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Last Name First Name

KAISER FOUNDATION HEALTH PLAN ARBITRATION AGREEMENT

I understand that (e

xcept 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 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.

Signature:

Today’s Date:

/ /

If you are the authorized representative, you must sign above and provide the following information:

Name:

Address:

Phone Number:

- -

Relationship to Enrollee:

Ofﬁce Use Only:

Name of staff member/agent/broker (if assisted in enrollment):

Plan ID #: Effective Date of Coverage:

/ /

ICEP/IEP: AEP: SEP (type): Not Eligible:

Page 5 of 5

2021 NCAL or SCAL Group Plan Election Form

483450253 10/2020

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