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
  • 185 other fields

Country of origin: US
File type: PDF

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Page 1 of 5
2022-KPIF-ACF-1 664802885 KPWA 2022
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
If you’re making a change, please update the boxes below with your new information. Please select one: I’m the
subscriber,
spouse/domestic
partner or dependent child 18 and older, or
parent or legal guardian
First name MI
Date of
birth (mm/dd/yyyy)
Last name
Medical record number (if any) Gender:
Male
Female
Phone I understand I may be contacted via text message.
-
-
Home address (no P.O. boxes, please)
City
State ZIP code County
Social Security number (if any)
-
-
Mailing address
Check if the same as the home address.
City
State ZIP code
Email address I understand I may be contacted via email.
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
2022-KPIF-ACF-1 664802885 KPWA 2022
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 — those marked with an asterisk (*) below — only for themselves.
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 coverage 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 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/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 coverage
(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/yyyy)
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 Choose one:
Spouse Domestic partner
Last name
Social Security number (if any)
-
-
Medical record number (if any)
Gender:
Male
Female
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 3 of 5
2022-KPIF-ACF-1 664802885 KPWA 2022
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 Social Security number (if
any)
Medical record number (if any) Gender:
Male Female
Date of birth (mm/dd/yyyy)
App
licants 21 and older: Have you u
sed 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 Social Security number (if
any)
Medical record number (if any) Gender:
Male
Female
Date of birth (mm/dd/yyyy)
App
licants 21 and older: Have you u
sed 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 Social Security number (if
any)
Medical record number (if any) Gender:
Male
Female
Date of birth (mm/dd/yyyy)
App
licants 21 and older: Have you u
sed 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
Social Security number (if any)
-
-
Medical record number (if any)
Gender:
Male
Female
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
2022-KPIF-ACF-1 664802885 KPWA 2022
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 the birth or placement of the child with you
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
Loss of COBRA health coverage due to discontinuation of
employer contribution
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 Br
onze
Silver HSA
Fle
x Silver HD
Flex Gold
Connect Network
Available in King, Kitsap, Pierce,
Snohomish, Spokane, and Thurston
counties
Virtual Plus Bronze
F.
Choose your dental plan
If you want to add dental coverage, please choose your dental plan here.
Under the Affordable Care Act, pediatric dental coverage is required. If
your account change form includes children 18 and younger and you
don’t enroll them in our pediatric dental plan, we’ll contact you to submit
an Attestation of Pediatric Coverage with proof of other pediatric dental
coverage.
Pediatric Dental #09140
Adult/F
amily Dental #09145
Page 5 of 5
2022-KPIF-ACF-1 664802885 KPWA 2022
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.
• If I worked with a producer, I understand they may receive monetary payments or other compensation from Kaiser Permanente in connection with this
coverage. Our standard compensation is $192, per member per year, plus a potential bonus. To learn more, visit kp.org/brokercompensation.
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 23127
San Diego, CA 92193-9921
Or fax to:
Membership Administration
1-855-355-5334
Questions? Call
1-800-290-8900 (TTY 711)
All medical plans offered and underwritten by Kaiser Foundation Health Plan of Washington, 1300 SW 27th Street, Renton, WA 98057.
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2021-XB-7_ACA_Notice_Taglines
Notice of Nondiscrimination
Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc.
(“Kaiser Permanente”) comply with applicable Federal and Washington state civil rights laws and do 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 communicate effectively with us,
such as:
– Qualified sign language interpreters
– Written information in other formats (large print, audio, accessible electronic formats, and
other 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 Member Services at 1-888-901-4636 (TTY 711).
If you believe that Kaiser Permanente has failed to provide these services or discriminated in another
way on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity,
you can file a grievance with our Civil Rights Coordinator by writing to P.O. Box 35191, Mail Stop:
RCR-A3S-03, Seattle, WA 98124-5191 or calling Member Services at the number listed above. You can file
a grievance by mail, phone, or online at kp.org/wa/feedback. If you need help filing a grievance, our 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, 1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html
• The Washington State Office of the Insurance Commissioner, electronically through the
Office of the Insurance Commissioner Complaint portal available at
https://www.insurance.wa.gov/file-complaint-or-check-your-complaint-status, or by phone at
800-562-6900, 360-586-0241 (TDD). Complaint forms are available at
https://fortress.wa.gov/oic/onlineservices/cc/pub/complaintinformation.aspx
XB0001444-57-21
Multi-language Interpreter 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 711).
Español (Spanish): ATENCIÓN: si habla otro idioma que no sea español, tiene a su disposición servicios
gratuitos de asistencia en su idioma. Llame al 1-888-901-4636 (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
1-888-901-4636 (TTY 711)。
Tiếng Việt (Vietnamese): CHÚ Ý: Nếu quý vị nói tiếng Việt, hiện có các dịch vụ hỗ trợ ngôn ngữ miễn phí
dành cho quý vị. Gọi số 1-888-901-4636 (TTY 711).
한국어 (Korean): 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수
있습니다. 1-888-901-4636 (TTY 711) 번으로 전화해 주십시오.
Русский (Russian): ВНИМАНИЕ! Если вы говорите на русском языке, вам доступны
бесплатные услуги перевода. Звоните 1-888-901-4636 (TTY 711).
Tagalog: PAUNAWA: Kung nagsasalita ka ng wika maliban sa Tagalog, maaari kang gumamit ng mga
serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-888-901-4636 (TTY 711).
Українська (Ukrainian): УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до
безкоштовної служби мовної підтримки. Телефонуйте за номером
1-888-901-4636 (TTY 711).
មែរ (Khmer)៖ សូមយកចិ
  
  1-888-901-4636 (TTY 711)
日本語 (Japanese): 注意事項：英語以外の言語を話される場合、無料の言語サポートをご利用
いただけます。1-888-901-4636 (TTY 711) まで、お電話にてご連絡ください。
አማርኛ (Amharic)፥ ማሳሰቢያ፥ የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እገዛ አገልግሎቶች፣ በነጻ ለእርስዎ
ይቀርባሉ ወደ ሚከተለው ቁጥር ይደውሉ 1-888-901-4636 (መስማት ለተሳናቸው 711)።
Oromiffa (Oromo): XIYYEEFFANNAA: Afaan dubbattu Oroomiffa yoo ta’e, tajaajila gargaarsa afaanii,
kanfaltiidhaan ala, ni argama. 1-888-901-4636 (TTY 711) irraatti bilbilaa.
 (Punjabi):  :     ,         
 1-888-901-4636 (TTY 711)  ਕ ਲ 
 :
:
 (Arabic) ةيبرعلا
1-888-901-4636 TTY 711
Deutsch (German): ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche
Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-888-901-4636 (TTY 711).
ພາສາລາວ (Lao): ໂປດຊາບ:  

 
  
    . 1-888-901-4636 (TTY 711).
2022-KPIF-ACF-1
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Instructions Account Change Form Kaiser Foundation Health Plan (Kaiser Permanente)

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