Please read the fol l owi n g before signing your form
The following statements are valid for the period of coverage I have selected under this plan for myself and my current
and future dependents who are or will be covered, unless I or my dependents provide written notiﬁcation of a change.
• I hereby acknowledge, on behalf of myself and my enrolled family members, that Kaiser Foundation Health Plan
of the Northwest (KFHPNW) may request personal health information, including information regarding treatment
or services that any of us may receive from a physician, health care practitioner, hospital, medical ofﬁce, or
other medical facility. I also acknowledge that KFHPNW or its authorized designee may use and disclose such
personal health information for treatment, payment, or health care operations without authorization in accordance
with applicable law. This is not an authorization for the Health Insurance Portability and Accountability Act
of 1996 (HIPAA).
• I allow any college, university, or educational institution to furnish KFHPNW with information necessary to establish
student eligibility under this plan.
• I allow the proper deductions, if any, to be made from my earnings as my part of the cost of this coverage.
• I understand that all non-emergency services (including services provided under Tier 1 of Added Choice
covered only when provided by or arranged by Participating Providers and Participating Facilities or Select Providers
and Select Facilities. (Added Choice members: See your Evidence of Coverage [EOC] for providers and facilities
covered under Tier 2 and Tier 3 for non-emergency services.)
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health
insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or
your dependents lose eligibility for that other coverage (or if the employer stopped contributing toward your or your
dependents’ other coverage). However, you must request enrollment within 30 days after your or your dependents’
other coverage ends (or after the employer stops contributing toward the other coverage).
In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you
may be able to enroll yourself and your dependents. However, you must request enrollment within 31 days after a
marriage, and within 60 days for a birth, adoption, or placement for adoption (if an additional premium is not required
to add a child, this requirement is waived).
To request special enrollment or obtain more information, contact Membership Services at one of the phone numbers
Obtaining services and prior authorization
If you are enroll ing in a Traditional, De ductible (HSA-Co mpa tible), or High De ductible medical or dental
plan: All services must be provided, prescribed, or directed by Participating Providers or Permanente Dental
Associates dentists, except for qualifying emergency and urgent care (outside our service area) or authorized referrals.
If you are enroll ing in Added Choice: All Tier 1 services must be provided, prescribed, or directed by Select
Providers, except emergency care and urgent care (outside our service area) or authorized referrals.
Prior authorization (all pl ans): Many services require prior authorization in order to be covered. For example, if you
are an Added Choice member, most Tier 2 and Tier 3 non-emergency care and procedures provided in a hospital,
another care facility, or your home, except for maternity care, must be authorized at least 72 hours in advance. See
your EOC or contact Membership Services to learn which services require prior authorization.
Temporary enrollment identiﬁ cation: Please make a copy of this form. You will soon receive a membership card.
Until then, present this form to Membership Services, located in most of our facilities, to receive services.
Membership S ervice s: For assistance with obtaining services, call Membership Services at 503-813-2000 in the
Portland area or 1-800-813-2000 from all other areas. For TTY, call 1-800-735-2900. For language interpretation
services, call 1-800-324 -8 010.
Submitting the enrollment application
This enrollment form is to be submitted by the employer. Please be sure the form is complete and includes the
employee’s signature. Missing or incomplete information may signiﬁcantly slow down the enrollment process.
Kaiser Permanente Membership Administration
PO Box 203012
Denver, CO 80220-9012
* Please limit fax submissions to one enrollment form per transmission.
©2010 Kaiser Foundation Health Plan of the Northwest