Fillable Instructions Account Change Form Kaiser Foundation Health Plan (Kaiser Permanente)

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Instructions Account Change Form Kaiser Foundation Health Plan (Kaiser Permanente)

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The Instructions Account Change Form Kaiser Foundation Health Plan (Kaiser Permanente) form is 5 pages long and contains:

  • 6 signatures
  • 18 check-boxes
  • 184 other fields

Country of origin: US
File type: PDF

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Page 1 of 5
2021-KPIF-ACF-1 485075532 KPWA 2021
Individual and Family Plans
Account Change Form
Kaiser Foundation Health Plan of Washington
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 for 2 plans or having
a gap in coverage, please cancel any other coverage they have as of the day before their new coverage starts.
• Note: If you’re entitled to Medicare Part A or enrolled in Medicare Part B, you’re not eligible to change Kaiser Foundation Health Plan of Washington
(KFHPWA) plans. If a family member is entitled to Medicare Part A or enrolled in Medicare Part B, they’re not eligible to change KFHPWA plans or be
added to your KFHPWA plan as a new dependent.
A. Fill out your information
Please select one: I’m the
subscriber,
spouse/domestic 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
Last name
Date of birth (mm/dd/yyyy)
Medical record number (if any) Social Security number (if any)
-
-
Phone
-
-
Home address (no P.O. boxes, please)
City State ZIP code
Mailing address
Check if the same as the home address.
City State ZIP code
Applicants 21 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 5
2021-KPIF-ACF-1 485075532 KPWA 2021
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 you don’t list.
•
The subscriber (or parent or legal guardian for subscribers under 18) can make all the changes below for any family members. Dependents 18 and
older can make changes for themselves for items marked with an asterisk (*) below.
You can make the following changes during open enrollment or a special enrollment period.
(Restrictions apply for special enrollment periods. See kp.org/specialenrollment for more information.)
I wish to change plans.*
I wish to combine accounts.
I wish to add medical coverage for a family member.
I wish to add medical coverage for myself on my family’s account as the subscriber.
I wish to add adult/family dental cover age for all members on this account.*
I wish to add pediatric dental coverage (for members 18 and younger).
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/domestic
partner as the subscriber.
I’m ending my cover age 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/domestic 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.)*
I wish to end my/our adult/family dental cover age
(everyone’s coverage will be canceled).*
I wish to end pediatric dental coverage for my dependent(s)
18 and younger.
Requested effective date (not guaranteed)
mm/dd/yy
C. Which family members are affected by the change? (Please list below.)
Spouse/Domestic partner
Add medical coverage
End medical coverage
Add adult dental coverage
End adult dental coverage
Add pediatric dental coverage
End pediatric dental coverage
First name
MI Last name
Choose one: Spouse
Domestic partner
Social Security number (if any)
-
-
Medical record number (if any) Date of birth (mm/dd/yyyy)
Gender:
Male
Female
Applicants 21 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 3 of 5
2021-KPIF-ACF-1 485075532 KPWA 2021
C. Which family members are affected by the change? (Please list below.)
If you have more than 4 dependents with a change, attach a copy of this page and complete the information for those dependents.
Dependent 1
Add medical coverage
End medical coverage
Add adult dental coverage
End adult dental coverage
Add pediatric dental coverage
End pediatric dental coverage
First name MI Last name Gender:
Male
Female
Social Security number (if any)
-
-
Medical record number (if any) Date of birth (mm/dd/yyyy)
Applicants 21 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
Add adult dental coverage
End adult dental coverage
Add pediatric dental coverage
End pediatric dental coverage
First name MI Last name Gender:
Male
Female
Social Security number (if any)
-
-
Medical record number (if any) Date of birth (mm/dd/yyyy)
Applicants 21 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
Add adult dental coverage
End adult dental coverage
Add pediatric dental coverage
End pediatric dental coverage
First name MI Last name Gender:
Male
Female
Social Security number (if any)
-
-
Medical record number (if any) Date of birth (mm/dd/yyyy)
Applicants 21 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 4
Add medical coverage
End medical coverage
Add adult dental coverage
End adult dental coverage
Add pediatric dental coverage
End pediatric dental coverage
First name MI Last name Gender:
Male
Female
Social Security number (if any)
-
-
Medical record number (if any) Date of birth (mm/dd/yyyy)
Applicants 21 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 5
2021-KPIF-ACF-1 485075532 KPWA 2021
D. Choose your enrollment period
Select one option:
Open enrollment (skip to Section E)
A special enrollment period (continue below)
Choose your qualifying life event. If you had more than one, review your options because effective dates vary by event. Proof of eligibility is also
required. Visit kp.org/specialenrollment or call 1-800-290-8900 for more about qualifying life events.
Loss of minimum essential health coverage (write the last full day you
had coverage)*
Did you lose coverage with us (KFHPWA) that was provided by
your employer?
Yes
No
If Yes, you have 2 options for continuing your coverage with us.
Coverage that begins automatically the day after your
employer coverage ends.
Coverage that begins based on when we receive your
application. Please see kp.org/specialenrollment under
“Loss of minimum essential health coverage” for more details.
Gaining or becoming a dependent through marriage or domestic
partnership
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 gaining the dependent
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
Permanent relocation with access to new plans
Changes in employer health coverage making you eligible for
a premium tax credit
Determination by Washington Healthplanfinder of exceptional
circumstances
Eligibility to purchase an individual health plan through
an individual coverage health reimbursement arrangement
(ICHRA) or a qualified small employer health reimbursement
arrangement (QSEHRA)
Domestic violence or spousal abandonment occurring within
the household
Please write the date of your qualifying life event.
(mm/dd/yyyy)
*
If
your qualifying life event is loss of KFHPWA coverage, we may review membership records to check when and why you lost coverage. For more about
minimum essential coverage, visit kp.org/specialenrollment.
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.
CoreSelect Network
Bronze
Bronze HSA*
Flex Bronze
Silver HSA*
Flex Silver HD
Flex Gold
Connect Network
Available in King, Kitsap, Pierce,
Snohomish, Spokane, and Thurston
counties
Virtual Plus Bronze
* HealthEquity administers a health savings account (HSA) that’s integrated with your KFHPWA medical plan.
Do you want to choose HealthEquity for your HSA?
Yes No
F. Choose your dental plan
If you want to add dental coverage, please choose your dental plan:
Pediatric Dental #09140
Adult/Family Dental #09145
Page 5 of 5
2021-KPIF-ACF-1 485075532 KPWA 2021
G. Sign the form
• It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company.
Penalties include imprisonment, fines, and denial of insurance benefits.
•
I verify that no one listed on this form who is changing plans or being added as a dependent is 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 Foundation Health Plan of Washington
Membership Administration
P.O. Box 34750
Seattle, WA 98124-1750
Or fax toll free to:
Membership Administration
206-630-7001
Questions? Call
1-800-290-8900 (TTY 711)
All medical plans offered and underwritten by Kaiser Foundation Health Plan of Washington, 601 Union St., Suite 3100, Seattle, WA 98101.
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Kaiser Permanente Nondiscrimination
Notice and Language Access Services
KAISER PERMANENTE NONDISCRIMINATION NOTICE
Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc.
(“Kaiser Permanente”) comply with applicable federal civil rights laws and does not discriminate, exclude
people, or treat them differently on the basis of race, color, national origin, age, disability, sex, sexual
orientation, gender identity, or any other basis protected by applicable federal, state, or local law. We also:
Provide free aids and services to people with disabilities to help ensure effective communication, such as:
• Qualified sign language interpreters
• Written information in other formats (large print, audio, and accessible electronic formats)
• Assistive devices (magnifiers, Pocket Talkers, and other aids)
Provide free language services to people whose primary language is not English, such as:
• Qualified interpreters
• Information written in other languages
If you need these services, contact Kaiser Permanente.
If you believe that Kaiser Permanente has failed to provide these services or discriminated in another way on
th
e basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity, you can file a
grievance. Please call us if you need help submitting a grievance. The Civil Rights Coordinator will be notified
of all grievances related to discrimination.
Kaiser Permanente
Phone: 206-630-4636
Toll-free: 1-888-901-4636
TTY Washington Relay Service: 1-800-833-6388 or 711
TTY Idaho Relay Service: 1-800-377-3529 or 711
Electronically:
kp.org/wa/feedback
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, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html
For Medic
are Advantage Plans Only: Kaiser Permanente is an HMO plan with a Medicare contract. Enrollment in
Kaiser Permanente depends on contract renewal.
© 2018
Kaiser Foundation Health Plan of Washington H5050_XB0001444_56_18 accepted
2018-XB-7_ACA_Notice_Taglines
LANGUAGE ACCESS SERVICES
English: ATTENTION: If you speak a language other than English, language assistance services, free of charge, are
available to you. Call 1-888-901-4636 (TTY: 1-800-833-6388 or 711).
Español (Spanish): ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.
Llame al 1-888-901-4636 (TTY: 1-800-833-6388 / 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
1-888-901-4636 (TTY: 1-800-833-6388 / 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 1-888-901-4636 (TTY: 1-800-833-6388 / 711).
한
국어(Korean): 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.
1-888-901-4636 (TTY: 1-800-833-6388 / 711) 번으로 전화해 주십시오.
Русский (Russian): ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги
перевода. Звоните 1-888-901-4636 (телетайп: 1-800-833-6388 / 711).
Filipino (Tagalog): PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa
wika nang walang bayad. Tumawag sa 1-888-901-4636 (TTY: 1-800-833-6388 / 711).
Українська (Ukrainian): УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до
безкоштовної служби мовної підтримки. Телефонуйте за номером 1-888-901-4636
(телетайп: 1-800-833-6388 / 711).

(Khmer)
 ,    

1-888-901-4636 (TTY: 1-800-833-6388 / 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。
1-888-901-4636 (TTY: 1-800-833-6388 / 711) まで、 お電話にてご連絡ください。
አማርኛ (Amharic) ፥ ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል ወደ ሚከተለው
ቁጥር ይደውሉ
1-888-901-4636 (መስማት ለተሳናቸው: 1-800-833-6388 / 711).
Oromiffa (Oromo): XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni
argama. Bilbilaa 1-888-901-4636 (TTY: 1-800-833-6388 / 711).
 (Punjabi)  :     ,          ।
1-888-901-4636 (TTY: 1-800-833-6388 / 711) ‘  ।
 (Arabic):        :          
 .   1-888-901-4636    . (711 / 1-800-833-6388) :
Deutsch (German): ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen
zur Verfügung. Rufnummer: 1-888-901-4636 (TTY: 1-800-833-6388 / 711).
 (Lao): :


, 



, 


,


 
.  1-888-901-4636 (TTY: 1-800-833-6388 / 711).
Srpsko-hrvatski (Serbo-Croatian): OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su
vam besplatno. Nazovite 1-888-901-4636 (TTY- Telefon za osobe sa oštećenim govorom ili sluhom:
1-800-833-6388 / 711).
Français (French): ATTENTION: Si vous parlez français, des services d’aide linguistique vous sont proposés
gratuitement. Appelez le 1-888-901-4636 (ATS: 1-800-833-6388 / 711).
Română (Romanian): ATENȚIE: Dacă vorbiți limba română, vă stau la dispoziție servicii de asistență lingvistică, gratuit.
Sunați la 1-888-901-4636 (TTY: 1-800-833-6388 / 711).
Adamawa (Fulfulde): MAANDO: To a waawi Adamawa, e woodi ballooji-ma to ekkitaaki wolde caahu. Noddu
1-888-901-4636 (TTY: 1-800-833-6388 / 711).

(Farsi):

:               
. 
1-888-901-4636 (TTY: 1-800-833-6388 / 711)
 .
XB0001444-56-18
2021-KPIF-ACF-1
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Instructions Account Change Form Kaiser Foundation Health Plan (Kaiser Permanente)

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