Fillable Georgia Region Group Enrollment/ Change Form for Large

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Georgia Region Group Enrollment/ Change Form for Large

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The Georgia Region Group Enrollment/ Change Form for Large form is 4 pages long and contains:

  • 3 signatures
  • 10 check-boxes
  • 169 other fields

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IF MAKING A CHANGE, COMPLETE THE FOLLOWING:
DELETE DEPENDENTS (Complete sections A, B, E, G) ADD DEPENDENTS (Complete sections A, B, E, G)
DATE (MM/DD/YYYY) DATE (MM/DD/YYYY)
Over age limit Birth
Divorce Adoption*
Deceased Marriage*
Other (please specify) Loss of other coverage
__________________________________________________
Other (please specify)
OTHER CHANGES (Complete sections A, B, G)
_____________________________________________________
Name change _________________________________________________________ Address (complete sections A, G)
Previous name ________________________________________________________ Telephone (complete sections A, G)
Current name _________________________________________________________
*Additional documentation may be required.
TO BE COMPLETED BY EMPLOYER (Please print or type in black ink only.)
COMPANY NAME
GROUP NO. SUBGROUP NO. BILLGROUP UNIT DATE OF HIRE (MM/DD/YYYY) EFFECTIVE DATE (MM/DD/YYYY)
NEW ENROLLMENT Check one:
New group Open enrollment (complete sections A, B, E, G)
New hire (complete sections A, B, E, G) COBRA (complete sections A, B, E, G)
Loss of other coverage (complete sections A, B, E, G)
Date of event
Other (please specify)
___________________________
Cancel all coverage (employee and family) (complete section A)
PLAN Check one: Signature HMO Multi-Choice Out-of-Area Consumer Choice Option (CCO)
HMO HSA-Qualified Deductible HMO (Self Only) HSA-Qualified Deductible HMO (Family)
Deductible Plan with HRA (Self Only) Deductible Plan with HRA (Family)
Page 1 of 4
A. EMPLOYEE INFORMATION—to be completed by the employee.
LAST NAME FIRST NAME MI SUFFIX
SOCIAL SECURITY NUMBER MEDICAL RECORD NUMBER (IF ANY) DATE OF BIRTH (MM/DD/YYYY) MALE FEMALE
Georgia Region Group Enrollment/
Change Form for Large Group
60526020 10/16
ADD DELETE SPOUSE DOMESTIC PARTNER
LAST NAME FIRST NAME MI SUFFIX
SOCIAL SECURITY NUMBER MEDICAL RECORD NUMBER (IF ANY) DATE OF BIRTH (MM/DD/YYYY) MALE FEMALE
Primary Care Physician (PCP) Name _______________________________________________________________________ PCP ID #
ADD DELETE DEPENDENT CHILD OTHER ______________________________
LAST NAME FIRST NAME MI SUFFIX
SOCIAL SECURITY NUMBER MEDICAL RECORD NUMBER (IF ANY) DATE OF BIRTH (MM/DD/YYYY) MALE FEMALE
Primary Care Physician (PCP) Name _______________________________________________________________________ PCP ID #
ADD DELETE DEPENDENT CHILD OTHER ______________________________
LAST NAME FIRST NAME MI SUFFIX
SOCIAL SECURITY NUMBER MEDICAL RECORD NUMBER (IF ANY) DATE OF BIRTH (MM/DD/YYYY) MALE FEMALE
Primary Care Physician (PCP) Name _______________________________________________________________________ PCP ID #
Page 2 of 4
B. FAMILY INFORMATION
LAST NAME SOCIAL SECURITY NUMBER
ADDRESS
APARTMENT NUMBER CITY
STATE ZIP CODE HOME PHONE WORK PHONE
Primary Care Physician (PCP) Name _______________________________________________________________________ PCP ID #
SPOKEN OR WRITTEN LANGUAGE ETHNICITY E-MAIL
_________________________
A. EMPLOYEE INFORMATION (continued)
Page 3 of 4
EMPLOYEE LAST NAME SOCIAL SECURITY NUMBER
C. Do any of your dependents above live at another address? YES NO If yes, please complete the following:
Name(s) (Last, First, MI) Address
E. OTHER COVERAGE INFORMATION
Including yourself, do any of the persons listed above have other coverage? YES NO
____________________________ ____________________________ ________________________ ________________________
Name Insurance carrier name Policy number Telephone number
D. Are any of your listed dependents over the maximum age? If yes, please complete the following:
Name(s) (Last, First, MI) Disabled* Full-time student* Name of college, university, or trade school
YES NO YES NO
YES NO YES NO
Are you or any of your dependants eligible for Medicare? YES NO
G. Important: Your application cannot be processed without your signature. Please read the back of this form before signing.
I acknowledge by my signature that the information I have supplied on this form is true and correct, and that I have read and
agree to the requirements, terms, conditions, limitations, and provisions described on the reverse sides.
_____________________________________________________ ____________________________________________________________________
Employee/Applicant signature Date Employer signature Date
*Additional documentation may be required.
Mail original to: Kaiser Foundation Health Plan of Georgia, Inc. • P.O. Box 203010 • Denver, CO 80220-9010
F. Waiver of coverage
By completing this section, I acknowledge that I was given
the opportunity to enroll in this plan of group health benefits
offered by my employer. I refuse the following:
All coverage Coverage for my spouse
Coverage for my children
I understand that if I or my dependents later wish to enroll
for any of the coverage(s) refused, I/they will be required
to submit an Employee Application and Change Form, and
coverage may be subject to late enrollee provisions, as
allowed by law and as directed by my employer.
Reason for refusal: (Please check all appropriate boxes)
other group coverage sponsored by my employer*
other group coverage sponsored by my spouse’s employer*
other group coverage sponsored by another organization*
other reasons (please explain)
________________________________________________________
*Please provide name of carrier:
________________________________________________________
*Plan number: Telephone number:
____________________________ __________________________
ADD DELETE DEPENDENT CHILD OTHER ______________________________
LAST NAME FIRST NAME MI SUFFIX
SOCIAL SECURITY NUMBER MEDICAL RECORD NUMBER (IF ANY) DATE OF BIRTH (MM/DD/YYYY) MALE FEMALE
Primary Care Physician (PCP) Name _______________________________________________________________________ PCP ID #
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Please complete this application and submit it to your company’s
Benefits Administrator. I understand and agree that if the applica-
tion is accepted by Kaiser Foundation Health Plan of Georgia, Inc.
(“Health Plan”) and Kaiser Permanente Insurance Company (“KPIC”),
as applicable, the benefits for which I, my spouse, and dependents
(if any) will be eligible will be in accordance with the Group Agree-
ment and/or Group Policy, as applicable to the type of plan for which
we are enrolled. I further understand and agree that I, my spouse,
and dependents (if any) will be bound by the terms and conditions of
such agreements. I authorize the deduction from my wages, amounts
necessary to pay the employee portion of the premiums for my, my
spouse’s, and covered dependents’ (if any) Health Plan and/or KPIC, as
applicable, coverage. I understand that to be eligible for coverage and
remain eligible, I must satisfy the eligibility requirements set forth in my
employer’s agreement with Health Plan, and that the information pro-
vided in this application may be relied on and used to determine my,
my spouse’s, and my dependents’ (if any) eligibility for such coverage.
I agree to provide any documentation, including tax returns, payroll
records, etc. necessary to establish that I, my spouse, and my de-
pendents (if any) initially met and continue to meet this or any other
requirement for coverage.
Dependent Eligibility Guidelines
1. To be a family dependent a person must be:
a. The subscriber’s spouse (eligibility for a spouse ends at the end of
the month in which a divorce is final). If the spouse has a different last
name than the subscriber, please attach to this application verification
of marriage.
b. Any unmarried, dependent child of the subscriber or the subscrib-
er’s spouse, or an unmarried, dependent child who is claimed on the
subscriber’s federal tax return and is under the group’s age limit for
dependent status.
2. Dependent children meeting the guidelines above may remain
under the subscriber’s contract until the group’s age limit for
dependent status. Refer to Evidence of Coverage.
3. Dependent children incapable of self-sustaining employment due
to mental retardation or physical handicap may remain under the
subscriber’s contract past the group’s age limit for dependent status.
Please complete a Coverage Request for Mentally Retarded or
Physically Handicapped Children Form and attach it to this applica-
tion. Dependent children must also meet requirement of 1b above.
4. If you have any questions concerning the benefits and services that
are provided by or excluded under this agreement, please contact
Customer Service at (404) 261-2590 before signing this application.
Personal Information
In order to review your application, information may be collected from
persons other than you and your covered family members. Information
which is collected may be disclosed to others without authorization
only as allowed by law. Each covered person has a right to review and
correct all personal information which is collected about him. A more
complete notice of our information practices is available upon request.
I authorize Kaiser Foundation Heath Plan of Georgia, Inc. (Health Plan)
and Kaiser Permanente Insurance Company (KPIC) to review existing
protected health information (PHI) and history of care provided to me
or my minor dependents for a period of 7 years preceding the date of
this application for membership in the Health Plan. This authorization
applies to information about any and all types of care that is reason-
ably related to determining my/our eligibility for membership in the
Health Plan, including, but not limited to, diagnosis and treatment
of mental health, alcohol/chemical dependency, HIV, AIDS, AIDS-
related conditions, medication history, pharmacy data, and
prescription history.
If accepted as a Health Plan member, I understand that Health Plan
and KPIC may, without limitation and including all categories of care
stated above, review and use my PHI following my/our actual enroll-
ment and initial usage of services in order to confirm consistency with
the information I submitted in this application or for such other pur-
poses as permitted by federal and/or state laws or regulations. I
understand that Health Plan and KPIC will not re-disclose any infor-
mation received except with my written consent, or as permitted
by federal and/or state laws or regulations. I understand that PHI
disclosed to others may no longer be protected by Kaiser Permanente
policy or the Health Insurance Portability and Accountability Act of
1996 (HIPAA). This authorization is effective for a period of 30 months
from the date this application is signed. I understand that I may revoke
this authoriza tion in writing at any time, except to the extent that
action has been taken based on this authorization. I understand that
revocation of an authorization used to secure a policy of insurance,
including health coverage from Kaiser Permanente, is not permitted
during the period of time the insurer may contest the policy issued or
a claim under the policy.
I further understand that to revoke this authorization I must send
a written revocation notice to: Kaiser Foundation Heath Plan of
Georgia, Inc., Nine Piedmont Center; 3495 Piedmont Road NE;
Atlanta, Georgia 30305.
NOTICES:
1. I understand and agree that any intentional material misstatement
or incomplete statement of fact provided on this application or the
failure to notify Kaiser Foundation Health Plan of Georgia, Inc. (Health
Plan) and /or Kaiser Permanente Insurance Company (KPIC), as ap-
plicable, of any change in health status or impairment or disease that
occurs between the date of application and the date coverage is ap-
proved will be deemed to be an intentional material misrepresentation
and may result in the rescission of my coverage, as well as the cover-
age of my spouse and covered dependents (if any), without liability to
Health Plan and/or KPIC, as applicable, The Southeast Permanente
Medical Group, Inc. and their affiliates. (If you are unsure of your
medical condition, please ask your physician to clarify your specific
medical condition.) If your coverage is rescinded, you may be billed
for services received.
2. You must immediately inform us if your health status or current
medication(s) change before your membership is approved for
coverage by the Health Plan. All updates should be signed, dated in
ink, and sent to Kaiser Permanente; Nine Piedmont Center;
3495 Piedmont Road NE; Atlanta, GA 30305.
3. This Plan has a network of participating physicians and other provid-
ers. My choice of physician or provider determines the level of benefits
I receive. Participating physicians and providers are subject to change.
I can view a current list of Kaiser Permanente physicians at kp.org.
Physicians and providers are paid in a number of ways, including salary,
capitation, case rates, fee for service, and incentive payments. I can
get more information about how participating physicians and provid-
ers are paid, request a Physician Directory, or obtain a list of current
participating physicians and other providers by calling Customer
Service at (404) 261-2590.
4. HMO plans and the Kaiser Permanente Select Provider benefit level
of the Multi- Choice plans are provided by Kaiser Foundation Health
Plan of Georgia, Inc. The PPO Provider and Non-participating Provider
benefit levels of the Multi-Choice plans and Out-of-Area PPO plans
are underwritten by Kaiser Permanente Insurance Company
IMPORTANT: Please read the conditions above, and sign and date
below. All applications MUST be signed in ink and dated by Primary
Applicant. I have read and understand all of the above conditions
and terms. I certify that the answers given are true and complete.
THIS IS YOUR APPLICATION FOR MEMBERSHIP
Signature of Employee ____________________________________________________________________________________________
Date ____________________________________ E-mail Address (optional) _____________________________________________
Page 4 of 4
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Kaiser Foundation Health Plan of Georgia, 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:
• 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 the number provided below.
Georgia 1-888-865-5813
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 with the Kaiser
Civil Rights Coordinator:
Nine Piedmont Center
3495 Piedmont Road, NE
Atlanta, GA 30305-1736
1-888-865-5813
You can file a grievance by mail or phone. If you need help filing a grievance, the Kaiser Civil Rights
Coordinator is available to help you. 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
1-800-868-1019
1-800-537-7697 (TTD)
Complaint forms are available at: http://www.hhs.gov/ocr/office/file/index.html
Have questions?
Call us at 1-800-494-5314.
•
Go to buykp.org/apply.
•
Or contact your agent or broker.
Kaiser Permanente for Individuals and Families
60436922 National 2016
Help in your Language
English: You have the right to get help in your language at no cost. If you have questions about
your application or coverage through Kaiser Permanente, or if this is a notice that requires you to take
action by a specific date, call the number provided for your state or region to talk to an interpreter.
Kaiser Foundation Health Plan, Inc., in Northern and Southern California and Hawaii
•
Kaiser Foundation Health Plan of Colorado
•
Kaiser Foundation Health Plan of Georgia, Inc., Nine
Piedmont Center, 3495 Piedmont Road NE, Atlanta, GA 30305, 404-364-7000
•
Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc., in Maryland, Virginia, and Washington,
D.C., 2101 E. Jefferson St., Rockville, MD 20852
•
Kaiser Foundation Health Plan of the Northwest, 500 NE Multnomah St., Suite 100, Portland, OR 97232
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Հայերեն (Armenian): Դուք ունեք Ձեր լեզվով անվճար
օգնություն ստանալու իրավունք: Եթե Դուք հարցեր
ունեք Ձեր դիմու կամ Kaiser Permanente-ի ջոցով
Ձեր ծածկույթի վերաբերյալ, կամ եթե սա ծանուցում է,
որը պարտադրում է Ձեզ, որպեսզի գործուղություններ
ձեռնարկեք նչև որոշակի ամսաթիվ, ապա
զանգահարե՛ք Ձեր նահանգի կամ շրջանի համար
տրամադրված հեռախոսահամարով` թարգմանչի հետ
խոսելու համար:
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Wɖ (Bassa):
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Kaiser Permanente
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বাংলা (Bengali): 
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Kaiser Permanente



California
............................ 1-800-464-4000
Colorado
............................ 1-800-632-9700
District of Columbia
..............1-800-777-7902
Georgia
.............................1-888-865-5813
Hawaii
...............................1-800-966-5955
Maryland
............................1-800-777-7902
Oregon
..............................1-800-813-2000
Virginia
..............................1-800-777-7902
Washington
........................1-800-813-2000
TTY
..................................................711
Have questions?
Call us at 1-800-494-5314.
•
Go to buykp.org/apply.
•
Or contact your agent or broker.
Kaiser Permanente for Individuals and Families
60436922 National 2016
Cebuano (Bisaya): Anaa moy katungod nga mangayo
og tabang sa inyo pinulongan ug kini walay bayad.
Kung naa mo pangutana bahin sa inyo aplikasyon
o coverage sa Kaiser Permanente, o kung kaning
pahibalo nanginahanglan sa inyo paglihok sa dili
pa usa ka piho nga petsa, palihug lang pagtawag
sa mga numero sa telepono nga gihatag sa imong
estado (“state”) o rehiyon (“region”) para makigstorya
sa usa ka interpreter.
中文 (Chinese): 您有權免費以您的語言獲得幫助。
如果您對您的Kaiser Permanente申請或承保有任何疑
問，或者如果本通知要求您在具體日期之前採取措施，
請致電您所在的州或地區的電話，與口譯員進行溝通。
Chuuk (Chukese): Mei wor omw pwuung omw kopwe
angei aninis non foosun fonuomw (Chuukese), ese
kamo. Ika mei wor omw kapas eis usun omw apilikeison
me/ika policy fan nemenien Kaiser Permanente, are
ika ei esinesin a erenuk pwe kopwe fori pwan ekoch
fofor, ka tongeni omw kopwe kori ewe nampa mei
kawor faniten omw state ika fonu (asan) iwe eman chon
chiakku epwe anisuk non kapasen fonuomw.
Français (French): Une assistance gratuite dans votre
langue est à votre disposition. Si vous avez des
questions à propos de votre demande d’inscription
ou de la couverture par Kaiser Permanente, ou si cet
avis vous demande de prendre des mesures à une
date précise, appelez le numéro indiqué pour votre
Etat ou votre région pour parler à un interprète.
Deutsch (German): Sie haben das Recht,
kostenlose Hilfe in Ihrer Sprache zu erhalten. Falls
Sie Fragen bezüglich Ihres Antrags oder Ihres
Krankenversicherungsschutzes durch Kaiser Permanente
haben oder falls Sie aufgrund dieser Benachrichtigung
bis zu bestimmten Stichtagen handeln müssen, rufen Sie
die für Ihren Bundesstaat oder Ihre Region aufgeführte
Nummer an, um mit einem Dolmetscher zu sprechen.
ગ
ુ
જરાતી (Gujarati): 

Kaiser Permanente






Kreyòl Ayisyen (Haitian Creole): Ou gen dwa pou jwenn
èd nan lang ou gratis. Si ou gen nenpòt kesyon sou
aplikasyon ou an oswa asirans ou ak Kaiser Permanente,
oswa si nan avi sa a gen bagay ou sipoze fè sa a avan yon
sèten dat, rele nimewo nou mete pou Eta oswa rejyon ou a
pou w ka pale ak yon entèprèt.
ʻōlelo Hawaiʻi (Hawaiian): He pono a ua loaʻa no kekahi
kōkua me kāu ʻōlelo inā makemake a he manuahi no hoʻi.
Inā he mau nīnau kāu e pili ana i kāu palapala noi ʻinikua
ola kino a i ʻole i kōkua maʻō ka polokalamu kōkua ola
kino Kaiser Permanente, a i ʻole inā ke haʻi nei paha kēia
leka nei iāʻoe e hana koke aku i kēia ma mua o kekahi lā
i waiho ʻia, e kelepona aku i ka helu i loaʻa ma kēia leka
nei no kāu mokuʻāina a i ʻole panaʻāina no ka walaʻau
ʻana me kekahi kanaka unuhi ʻōlelo.
हिन् (Hindi):


 Kaiser Permanente  
  
 
  
 

Hmoob (Hmong): Koj muaj cai kom tau txais kev pab
uas hais koj hom lus yam tsis tau them nqi. Yog koj muaj
lus nug txog koj daim ntawv thov los yog cov kev pab
them nyiaj tim Kaiser Permanente, los yog tias daim
ntawv no yog ib tsab ntawv ceebtoom uas yuav kom koj
ua ib yam dabtsi raws li hnub tau teev tseg, hu rau tus
nab npawb xovtooj uas tau muab rau koj lub xeev lossis
cheeb tsam kom tau tham nrog tus kws txhais lus.
Igbo (Igbo): Ị nwere ikike ịnweta enyemaka n’asụsụ
gị na akwụghị ụgwọ ọ bụla. Ọ bụrụ na ị nwere ajụjụ
gbasara akwụkwọ anamachọihe gị ma ọ bụ mkpuchi
si na Kaiser Permanente, ma ọ bụ ọ bụrụ na nke bụ
ọkwa a chọrọ ka ị mee ihe tupu otu ụbọchị, kpọọ nọmba
enyere maka steeti ma ọ bụ mpaghara gị iji kwukọrịta
okwu n’etiti onye ọkọwa okwu.
Iloko (Ilocano): Adda ti karbenganyo a dumawat iti tulong
iti pagsasaoyo nga awan ti bayadanyo. No addaankayo
kadagiti saludsod maipanggep ti aplikasionyo wenno
coverage babaen ti Kaiser Permanente, wenno no daytoy
ket maysa a pakdaar a kalikagumanna a rumbeng nga
aramidenyo ti addang iti espesipiko a petsa, tawagan ti
numero nga inpaay para ti estado wenno rehion tapno
makipatang ti maysa mangipatarus iti pagsasao.
Option 1
Have questions?
Call us at 1-800-494-5314.
•
Go to buykp.org/apply.
•
Or contact your agent or broker.
Kaiser Permanente for Individuals and Families
60436922 National 2016
Italiano (Italian): Hai il diritto di ricevere assistenza
nella tua lingua gratuitamente. In caso di domande
riguardanti la tua richiesta o la copertura attraverso
Kaiser Permanente, o se occorre intervenire entro
una data specifica secondo quanto indicato in questa
comunicazione, chiama il numero fornito per il tuo
stato o la tua regione per parlare con un interprete.
日本語 (Japanese): あなたは、費用負担なしでご使用
の言語で支援を受ける権利を保持しています。お申し
込みまたはKaiser Permanenteの担保範囲に関してご
質問があるか、または本通知により、あなたが特定の
日付までに行動を起こすよう依頼されている場合、お
住まいの州または地域に対して提供された電話番号に
電話して、通訳とお話ください。
 (Khmer): 





 


Kaiser Permanente











한국어 (Korean): 귀하에게는 한국어 통역서비스를
무료로 받으실 수 있는 권리가 있습니다.
Kaiser Permanente를 통한 귀하의 보험 신청서나 보험
보장 범위에 관해 질문이 있을 경우 또는 이 통지서의
요구대로 어느 날짜까지 조취를 취해야만 하는 경우,
귀하의 주 및 지역의 제공된 전화번호로 연락해 통역사와
통화하십시오.
ລາວ (Laotian): ທ່ານມີສິດທີ່ຈະໄດ້ຮັບການຊ່ວຍເຫຼືອໃນພາສາ
ຂອງທ່ານໂດຍບໍ່ເສັຽຄ່າ. ຖ້າວ່າ ທ່ານມີຄໍາຖາມກ່ຽວກັບການສະໝັກ
ຂອງທ່ານ ຫຼື ການຄຸ້ມຄອງຜ່ານ Kaiser Permanente, ຫຼື
ຖ້າອັນນີ້ເປັນແຈ້ງການທີ່ຮຽກຮ້ອງໃຫ້ທ່ານດໍາເນີນການພາຍໃນ
ວັນທີທີ່ເຈາະຈົງໃດໜຶ່ງ, ໃຫ້ໂທຕາມໝາຍເລກທີ່ໃຫ້ໄວ້ສໍາລັບລັດ
ຫຼື ເຂດຂອງທ່ານ ເພື່ອຂໍລົມກັບນາຍພາສາ.
Kajin Majōḷ (Marshallese): 


Kaiser Permanente



Naabeehó (Navajo): T’11 ni nizaad bee n7k1 i’doolwo[ doo
bik’4 as7n7[11g00 47 bee n1haz’3. Kaiser Permanente 1k1
an1’1lwo’ n1 bik’4 azl1adoo y7n7keedgo naaltsoos hadinilaa,
47 b7na’7d7[kid doogo, 47 doodago d77 naaltsoos haa’7da
yoo[k1a[go hait’1oda 7’d77l77[ ni[n7igo 47 nitsaa hahoodzoj7
47 doodago t’11 aadi nahós’a’di ata’ dahalne’7g77 bich’8’
h0lne’go bee bi[ ahi[ hod77lnih.
नेपाल (Nepali):  

Kaiser Permanente  
 




Afaan Oromoo (Oromo): Baasii malee afaan keetiin
gargaarsa argachuudhaaf mirga qabda. Waa’ee iyyata
keetii yookaan tajaajila Kaiser Permanente hammatu
ilaalchisee gaaffii yoo qabaatte, yookaan yoo kun
beeksisa guyyaa murtaa’e irratti tarkaanfii akka ati
fudhattu gaafatu ta’e, lakkoofsa bilbilaa naannoo
yookaan goodina keetiif kenname bilbiluudhaan
turjumaana haasofsiisi.
 :(Persian) یسراف

Kaiser Permanente


lokaiahn Pohnpei (Pohnpeian): 


Kaiser Permanente




Português (Portuguese): Você tem o direito de obter
ajuda em seu idioma sem nenhum custo. Se você
tiver dúvidas sobre sua solicitação ou cobertura
por meio da Kaiser Permanente, ou se este aviso
exigir que você tome alguma medida até uma data
específica, ligue para o número fornecido para seu
estado ou região para falar com um intérprete.
Have questions?
Call us at 1-800-494-5314.
•
Go to buykp.org/apply.
•
Or contact your agent or broker.
Kaiser Permanente for Individuals and Families
60436922 National 2016
 (Punjabi): 

Kaiser Permanente
  

 
Română (Romanian): Aveți dreptul de a solicita
ajutor care să vă fie oferit în mod gratuit în limba
dumneavoastră. Dacă aveți întrebări legate de
solicitarea dumneavoastră sau de acoperirea oferită
de Kaiser Permanente sau dacă acest aviz vă solicită
să luați măsuri până la o anumită dată, sunați la
numărul de telefon furnizat pentru statul sau regiunea
dumneavoastră pentru a sta de vorbă cu un interpret.
Pусский (Russian): 


Kaiser Permanente




Faa-Samoa (Samoan): E iai lou ‘aia e maua se
fesoasoani i lou gagana e aunoa ma le totogi. Afai e iai
ni fesili e uiga i lou tusi apalai po o puipuiga e ala mai
Kaiser Permanente, po o lenei tusi e manaomia ona e
gaoioi i se taimi atofaina, vili le numera ua fuafuaina mo
lou setete po o oganuu e fesoota’i i se faaliliu.
Español (Spanish): Usted tiene derecho a obtener
ayuda en su idioma sin costo alguno. Si tiene
preguntas acerca de su solicitud o cobertura a través
de Kaiser Permanente, o si este es un aviso que
requiere que usted tome alguna medida antes de
una fecha determinada, llame al número de teléfono
que se proporciona para su estado o región para
hablar con un intérprete.
Tagalog (Tagalog): Mayroon kang karapatang
humingi ng tulong sa iyong wika nang walang bayad.
Kung mayroon kang mga katanungan tungkol sa
iyong aplikasyon o coverage sa pamamagitang
ng Kaiser Permanente, o kung ito ay abisong
nangangailangan ng iyong aksyon sa tiyak na petsa,
tumawag sa numerong ibinigay para sa iyong estado
o rehiyon para makipag-usap sa isang interpreter.
ไทย (Thai): 
 




 Kaiser Permanente

  
  


Lea Faka-Tonga (Tongan): ‘Oku ‘ia ho totonu ke ke
ma’u ha fakatonulea ta’etotongi. Kapau ‘oku ‘i ai ha’o
fehu’i ki ho tohi kole na’e fakafonu ki he malu’i ‘inisiua
‘a e Kaiser Permanente, pea kapau ko e tohini ‘oku
fiema’u keke fai ha me’a ki ai pe ko ha ‘aho na’e tuku
pau atu ke fai ia, taa ki he fika kuo ‘oatu ki ho siteiti pe
ko e vahefonua ‘oku ke ‘i ai ke talanoa mo ha tokotaha
tene fakatonu lea atu kiate koe.
Українська (Ukrainian): 


Kaiser Permanente




:(Urdu) ودر
ُ
ا

Kaiser Permanente



Tiếng Việt (Vietnamese): 


Kaiser Permanente



Yorbá (Yoruba): 






Kaiser Permanente


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




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Georgia Region Group Enrollment Change Form for Large

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Completed 3 November 2021

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