Fillable Form 3578360780: Instructions Account Change Form Colorado Individual

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Form 3578360780: Instructions Account Change Form Colorado Individual

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The Form 3578360780: Instructions Account Change Form Colorado Individual form is 6 pages long and contains:

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  • 13 check-boxes
  • 155 other fields

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Page 1 of 6
357836078 Colorado 2020
Individual and Family Plans
3578360780
Account Change Form
Colorado
Instructions
• There are different types of plan changes and account changes you can make with this form. Please fill out your personal information in Section A.
Then select what changes you’d like to make in Section B, and continue on to fill out any other sections related to those changes.
• If you’re adding a dependent to your plan, any other coverage they have won’t be automatically canceled. To avoid paying 2 premiums or having
a gap in coverage, make sure to cancel any other coverage they have as of the day before their new coverage starts.
• Note: If you or any dependent you’re applying for are entitled to Medicare Part A or enrolled in Medicare Part B, you’re not eligible to switch
Kaiser Permanente Individual and Family (KPIF) plans.
A. Fill out your information
Please select one: I’m the subscriber, spouse/civil union partner, or dependent child 18 and older, or parent or legal guardian
If you’re making a change, please update the boxes below with your new information.
First name MI Gender:
Male Female
Undeclared
Last name
Date of birth (mm/dd/yyyy)
Health record number (if any) Social Security number (if any)
-
-
Phone
-
-
Home address (no P.O. boxes, please)
City State ZIP code
Billing address
Check if the same as the home address.
City State ZIP code
Applicants 18 and older: Have you 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
Page 2 of 6
357836078 Colorado 2020
B. What change(s) do you want to make?
• Please check the boxes below for the changes you wish to make, and on the next page, list each family member affected. We won’t make any changes
for any family members on your account you don’t list.
• Subscribers (or the parent or legal guardian for subscribers under 18) can make all the changes below for any family members. Dependents can make
some of the changes, only for themselves — see those changes marked with an asterisk (*) below.
You can make the following changes any time during the year. (Note: For these changes, you can skip Sections D and E.)
I’m ending my coverage and I wish to have my spouse/civil union
partner as the subscriber.
I’m ending my coverage on a family plan and wish to continue
on my own on an individual plan.*
I wish to change the subscriber.
I wish to change the parent/legal guardian on a child-only account.
I wish to end medical coverage for myself* or for a family member.
I’m ending my coverage but wish to keep my child(ren) on the plan.
I’m ending my and my spouse’s/civil union partner’s coverage
but wish to keep our child(ren) on the plan.
I wish to make the changes shown in Section A. (If you’re changing
your name, please include legal documentation of the change.)*
Someone on my account stopped using tobacco.
(Please indicate which family member in Section C.)*
You can make the following changes only during open enrollment or a special enrollment period.
(Restrictions apply for special enrollment periods. See kp.org/specialenrollment for more information.)
I wish to combine accounts.
I wish to add medical coverage for a family member.
I wish to change plans.*
Page 3 of 6
357836078 Colorado 2020
C. Which family members are affected by the change? (Please list below.)
If you have more than 3 dependents with a change, attach a copy of this page and complete the information for those dependents.
Spouse/Civil union partner
Add medical coverage
End medical coverage
First name
MI Last name
Choose one:
Spouse
Civil union partner
Social Security number (if any) Health record number (if any) Date of birth (mm/dd/yyyy)
Gender:
Male
Female
Undeclared
-
-
Applicants 18 and older: Have you used tobacco at least 4 times per week in the past 6 months (except for religious/ceremonial use)?
Pr
oducts include cigarettes, cigars, and chewing/smokeless tobacco. Regular tobacco users may pay different premiums.
Yes No
Dependent 1
Add medical coverage
End medical coverage
First name MI Last name Gender:
Male
Female
Undeclared
Social Security number (if any) Health record number (if any) Date of birth (mm/dd/yyyy)
-
-
Applicants 18 and older: Have you 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
Dependent 2
Add medical coverage
End medical coverage
First name
MI Last name Gender:
Male
Female
Undeclared
Social Security number (if any) Health record number (if any) Date of birth (mm/dd/yyyy)
-
-
Applicants 18 and older: Have you 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
Dependent 3
Add medical coverage
End medical coverage
First name
MI Last name Gender:
Male
Female
Undeclared
Social Security number (if any) Health record number (if any) Date of birth (mm/dd/yyyy)
-
-
Applicants 18 and older: Have you 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
Page 4 of 6
357836078 Colorado 2020
D. When are you making a change?
Select one option: Open enrollment (skip to Section E) A special enrollment period (continue below)
Choose the life event that made you eligible for a special enrollment period (please choose only one):
Loss of health care coverage (write the last full day you had coverage)*
Gaining or becoming a dependent through marriage or civil union
partnership
Gaining or becoming a dependent through the birth of a child, adoption,
foster care, 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, foster care, or placement for adoption
or foster care
The first day of the month after gaining the dependent
Losing a dependent through divorce, civil union partnership, or
legal separation
Death of the subscriber or a dependent
Child support order or other court order to cover a child
or dependent
Please choose one of the following for your effective date:
Date the court order is effective
Effective date assigned at time of application
Permanent relocation
Change in eligibility for employer he
alth coverage
Determination by DOI Insurance Commissioner
Domestic violence or spousal abandonment
Contract violation
Loss of short-term health coverage
Change in eligibility for a He
alth Reimbursement Account (HRA)
Release from incarceration
Change in eligibility for feder
al financial assistance through
Connect for Health Colorado**
Please write the date of your qualifying life event. (mm/dd/yyyy)
Proof of eligibility is required. Please visit kp.org/specialenrollment or call Denver/Boulder: 1-303-338-3800, Northern Colorado: 1-844-201-5824,
Southern Colorado: 1-888-681-7878 for more information.
*
If your qualifying life event is loss of Kaiser Permanente coverage, we may review your membership records to check when and why you lost coverage.
**If you’ll be getting federal financial assistance, don’t use this form. We can help you apply at Connect for Health Colorado.
Page 5 of 6
357836078 Colorado 2020
E. Choose your health plan
If you indicated that you would like to change plans or add coverage for a family member, please select the plan you would like here. Each family
member you listed in Section C will be moved to the plan you select. If you wish to enroll family members in different plans, please submit a separate
form for each plan.
Bronze
KP CO Bronze 7000/50
KP Select CO Bronze 7000/50
‡
KP CO Bronze 6000/50 RX Copay
KP Select CO Bronze 6000/50 RX Copay
‡
KP CO Bronze 5500/30%/HSA
KP Select CO Bronze 5500/30%/HSA
‡
KP CO Bronze 5500/50
KP Select CO Bronze 5500/50
‡
Silver
KP CO Silver 4500/20 X
KP Select C
O Silver 4500/20 X
‡
KP CO Silver 3500/30 RX Copay X
KP Select CO Silver 3500/30 RX Copay X
‡
KP CO Silver 3000/20%/HSA X
KP Select CO Silver 3000/20%/HSA X
‡
KP CO Silver 2500/25 X
KP Select CO Silver 2500/25 X
‡
Gold
KP CO Gold 1750/20
KP Select C
O Gold 1750/20
‡
KP CO Gold 1250/20
KP Select CO Gold 1250/20
‡
KP CO Gold 0/20 RX Copay
KP Select CO Gold 0/20 RX Copay
‡
Catastrophic plan
To purchase a Catastrophic plan, applicants must be younger than 30 on the effective date, or provide a certificate of exemption that shows hardship
or lack of affordable coverage. We won’t be able to process your application without the certificate of exemption if you are 30 and older. To see if you
qualify, please go to marketplace.cms.gov/applications-and-forms/hardship-exemption.pdf and follow the instructions.
KP CO Catastrophic/KP Select CO Catastrophic
‡
This plan does not offer pediatric dental benefits. If you are applying for this plan and have children under age 19 who will be covered, you must
purchase pediatric dental coverage separately.
I do not have children under age 19 who will be covered under this plan.
I hereby attest that I have or will purchase pediatric dental essential health benefit (EHB) coverage.
X
Applicant’s signature
For information about health and dental benefits and limitations, cost-sharing amounts, and premiums, please review the details in your enrollment
materials.To request a copy of the Evidence of Coverage for a particular plan, please go to kp.org/plandocuments, call Denver/Boulder: 1-303-338-3800,
Northern Colorado: 1-844-201-5824, Southern Colorado: 1-888-681-7878, or contact your broker.
‡
If you live in the Colorado Springs service area, your plan will be in the KP Select network. Please see the KPIF Enrollment Guide for important information
on plans in the KP Select network.
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Page 6 of 6
357836078 Colorado 2020
F. Sign the form
• If a broker has assisted you with this account/plan change, by signing below, you are giving permission to that broker to act on your behalf regarding
this account/plan change.
It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or
attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or
agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the
purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds
shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
I understand that Kaiser Permanente will rely on the information provided in this form. If any information is found to be fraudulent or intentionally
misrepresented, then Kaiser Permanente may choose to terminate coverage back to the coverage effective date.
• I verify that I am not entitled to Medicare Part A or enrolled in Medicare Part B.
Note: The subscriber and all dependents 18 and older making a change must sign the form. If there are more than 4 dependents 18 and older
signing, please attach a copy of this page with the additional signatures.
X
Subscriber/new subscriber (parent or legal guardian for subscribers under 18)
Date (mm/dd/yyyy)
X
Spouse/domestic partner
Date (mm/dd/yyyy)
X
Dependent (18 and older)
Date (mm/dd/yyyy)
X
Dependent (18 and older)
Date (mm/dd/yyyy)
X
Dependent (18 and older)
Date (mm/dd/yyyy)
X
Dependent (18 and older)
Date (mm/dd/yyyy)
Contact information
Mail to: Kaiser Permanente
P.O. Box 203004
Denver, CO 80220-9004
Or fax toll free to:
Membership Administration
1-866-846-2650
Questions? Call
1-866-410-7536
All plans are offered and underwritten by
Kaiser Foundation Health Plan Kaiser Foundation Health Plan of Colorado, 10350 E. Dakota Ave., Denver, CO 80247.
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NONDISCRIMINATION NOTICE
Kaiser Foundation Health Plan of Colorado (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:
Provide 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
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 1-800-632-9700 (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 at: Customer Experience
Department, Attn: Kaiser Permanente Civil Rights Coordinator, 2500 South Havana,
Aurora, CO 80014, or by phone at Member Services: 1-800-632-9700.
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.
____________________________________________________________________
HELP IN YOUR LANGUAGE
ATTENTION: If you speak English, language assistance services, free of charge,
are available to you. Call 1-800-632-9700 (TTY: 711).
አማርኛ (Amharic) ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት
ተዘጋጀተዋል ወደ ሚከተለው ቁጥር ይደውሉ 1-800-632-9700 (TTY: 711).
 (Arabic) :
1-800-632-9700TTY
Ɓa
̌
sɔ
́
ɔ
̀
Wu
̀
ɖu
̀
(Bassa) Dè ɖɛ nìà kɛ dyéɖé gbo:
às
-wùù-po-ny

ní, nìí, à wuu kà kò ò po-po


1-800-632-9700 (TTY: 711)
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
1-800-632-9700（TTY：711）。
60577108_ACA_1557_MarCom_CO_2017_Taglines
 (Farsi) 
 (711 :TTY) 1-800-632-9700
Français (French) ATTENTION: Si vous parlez français, des services d'aide
linguistique vous sont proposés gratuitement. Appelez le 1-800-632-9700 (TTY: 711).
Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen
kostenlos sprachliche Hilfsdienstleistungen zur Verfügung.
Rufnummer: 1-800-632-9700 (TTY: 711).
Igbo (Igbo) NRỤBAMA: br na na as Igbo, r enyemaka assr g.
Kp 1-800-632-9700 (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。1-800-632-9700（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. 1-800-632-9700 (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 1-800-632-9700 (TTY: 711).
Nepali) 


1-800-632-9700TTY: 711

Afaan Oromoo (Oromo) XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila
gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 1-800-632-9700 (TTY: 711).
Pусский (Russian) ВНИМАНИЕ: e
1-800-632-9700 (TTY: 711).
Español (Spanish) ATENCIÓN: si habla español, tiene a su disposición servicios
gratuitos de asistencia lingüística. Llame al 1-800-632-9700 (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 1-800-632-9700 (TTY: 711).
Tiếng Việt (Vietnamese) CHÚ Ý: Nu bn nói Ting Vit, có các dch v h tr
ngôn ng min phí dành cho bn. Gi s 1-800-632-9700 (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 1-800-632-9700 (TTY: 711).
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Form 3578360780: Instructions Account Change Form Colorado Individual

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Completed 7 January 2021

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