Fillable Kaiser Enrollment Change Form (University of Portland)

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Kaiser Enrollment Change Form (University of Portland)

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This section to be completed by the employer.
Company name* Effective date of coverage* / /
Group no.* Medical subgroup no. Billgroup Date of hire* / /
Dental subgroup no. Billgroup
  PAR T I:  PAR T II: Enrollmen t/change reason—complete if e xisting grou p* (Please check one.) Event date / /
New group New hire Newborn Loss of coverage Part-time to full-time Change
Existing group Open enrollment COBRA State continuation Other
A Employee information (Employee completes sections A, B, and C.)
Select benefit type: Medical (plan choice) Dental (plan choice)
Name (last, first, MI)*
Former/maiden name (if any)
Gender* M F Date of birth* / / Social Security no.
Home address* Apt.
City State ZIP E-mail
Home phone* Work phone
Health record no. (if any) Preferred language Ethnicity
B Dependent information (For additional dependents, please use our “Additional Dependent” form.)
Spouse Domestic partner** Name (last, first, MI) Disabled Yes No
Gender* M F Date of birth* / / Social Security no. Medical Dental
Other health insurance Yes No Insurance co. Policy no.
Health record no. (if any) Medicare eligible Yes No Medicare ID no.
Child name (last, first, MI) Full-time student Disabled Yes No
Gender* M F Date of birth* / / Social Security no. Medical Dental
Other health insurance Yes No Insurance co. Policy no.
Health record no. (if any) Medicare eligible Yes No Medicare ID no.
Child name (last, first, MI) Full-time student Disabled Yes No
Gender* M F Date of birth* / / Social Security no. Medical Dental
Other health insurance Yes No Insurance co. Policy no.
Health record no. (if any) Medicare eligible Yes No Medicare ID no.
Child name (last, first, MI) Full-time student Disabled Yes No
Gender* M F Date of birth* / / Social Security no. Medical Dental
Other health insurance Yes No Insurance co. Policy no.
Health record no. (if any) Medicare eligible Yes No Medicare ID no.
Check here if “Additional Dependent” form is attached.
C Important—Your application cannot be processed without your signature. Please read pages 2–3 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 pages 2–3 of this form.
Employee signature*
Date / /
**Required
**A person legally recognized as your domestic partner in a valid Certificate of Registered Domestic Partnership issued by the state of Oregon or who is
otherwise recognized as your domestic partner under criteria agreed upon, in writing, by Kaiser Foundation Health Plan of the Northwest and your Group.
Oregon group
employee enrollment/change form
535CORE-10/1-10FOENRL0110
All plans offered and underwritten by Kaiser Foundation Health Plan
of the Northwest. 500 NE Multnomah St., Ste. 100, Portland, OR 97232
See instructions on pages 2–3 before completing this form.
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
®
) are
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
listed below.
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.
By mail: 
Kaiser Permanente Membership Administration
PO Box 203012
Denver, CO 80220-9012
By fax:* 
1-866-311-5974
* Please limit fax submissions to one enrollment form per transmission.
FOENRL0110
©2010 Kaiser Foundation Health Plan of the Northwest
How to fill out this form
1. To be enrolled, you must live or work within
the Northwest service area at least 50 percent
of the time, unless you are an Added Choice
®
member.
2. Your employer must complete the employer
section. Your employer is responsible for
confirming all information before submitting
it, especially effective dates, as these affect
your premium.
3. You must complete sections A through C. In
section A, fill out information about yourself.
Fill out section B if you are enrolling any
dependents. Be sure to include any former last
names for dependents. The full-time student
box should only be marked if your dependent
qualifies as an overage dependent attending
school. Please contact your employer about the
rules for coverage of dependent students. Read
section C and the back of the form. Then sign
and date the form.
4. Once the form is complete, make a copy for
your records. (You will soon get a membership
ID card. Until then, you can use a copy of
your enrollment form to identify yourself as a
member at medical offices.)
All effective dates will be made in accordance with
the contractual agreement between the group
(your employer) and Kaiser Foundation Health Plan
of the Northwest.
Call Membership Services 8 a.m. to 6 p.m., Monday
through Friday. For TTY, call 1-800-735-2900. For
language interpretation services, call 1-800-324-8010.
Questions?
Portland
503-813-2000
All other areas
1-800-813-2000
Get connected
I’m a new member!
Your mem bership ID card
You will soon be receiving a membership ID card
containing your name and unique eight-digit health
record number. You’ll want to have this card handy
when you call for an appointment, speak to an advice
nurse, or come to us for care. If you don’t have your
ID card before your first appointment, bring a copy of
your enrollment form with you.
Transfer your medical records
Call Membership Services to request a release form
(phone numbers on reverse side). Then send the
completed and signed form to your previous health care
provider. That provider should send your records to:
Health Information Management
Regional Process Center
10220 SE Sunnyside Road
Clackamas, OR 97015
Transfer your prescrip t io ns
Usually we can arrange a one-time refill of a
prescription written by your previous doctor. Call
the main pharmacy number in your medical office at
least three days before you need the refill. Certain
prescriptions require that you see a Participating or
Select Provider before we can refill them. Once you
have this prescription, you have the option of filling it
online with postage-paid mail delivery.
Your online services
As a Kaiser Permanente member, you can take
advantage of our convenient online services. Our most
popular features include viewing lab results, requesting
prescription refills, e-mailing your doctor’s office, and
requesting or canceling appointments.
Once you receive your membership card with your
eight-digit health record number, you can get access to
these features and more by registering and logging on
to kp.org.
All plans offered and underwritten by Kaiser Foundation Health Plan
of the Northwest. 500 NE Multnomah St., Ste. 100, Portland, OR 97232.
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Kaiser Enrollment Change Form (University of Portland)

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Completed 25 July 2020

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