Kaiser

EMPLOYEE ENROLLMENT
Please print neatly. Be sure to fill in the enrollment form completely. Missing or inaccurate information will delay enrollment processing.

This form serves as your temporary Kaiser Permanente member ID. Please make a copy and keep it until you receive your official member ID.
EMPLOYEE ENROLLMENT
Please choose from the following*

New group accountExisting account
Company name*
Customer ID (if assigned)
Requested date of coverage*

MonthDayYear
Date
Plan selection
Employee classification (if applicable)
Employee name*
Date of Hire

MonthDayYear
Date
Enrollment reason Please check one*

New group accountNew hireOpen enrollmentPart-time to full-timeLoss of coverage
B TO BE COMPLETED BY EMPLOYEE
Have you ever been a member of, or received care from, Kaiser Permanente in California?*

YesNo
IF you have had care from Kaiser Permanente before, under what medical record number?
Name (Last, First, MI)*
Social Security number*
Preferred language (optional)
Address*

Street Address Line 2

CityState / Province

City, State, Zip
First day of residency at this address*
Date of birth*
Gender*

MF
C FAMILY INFORMATION Please list only those family members to be enrolled

SpouseDomestic partner
Date of birth (mm/dd/yyyy)
Gender

MF
Social Security number
Name (Last, First, MI)
Medical record number (if known)
Family Information

Dependent
Date of birth (mm/dd/yyyy)
Gender

MF
Social Security number
Name (Last, First, MI)
Medical record number (if known)
Additional dependents can be added at the end of the form. See section E
Do any of your dependents listed above live at another address?

NoYes
If Yes, complete the following:
Name (Last, First, MI)
Address

Street Address

CityState

Zip Code
EMPLOYEE ENROLLMENT
D SIGNATURE
KAISER FOUNDATION HEALTH PLAN, INC., AND KAISER PERMANENTE INSURANCE COMPANY ARBITRATION AGREEMENT*

I understand that (except for Small Claims Court cases, claims subject to a Medicare appeals procedure, and, if I am enrolled in coverage that is subject to the ERISA claims procedure regulation, or any claims that cannot be subject to binding arbitration under governing law) any dispute between myself, my heirs, relatives, or other associated parties on the one hand and Kaiser Foundation Health Plan, Inc. (KFHP), Kaiser Permanente Insurance Company (KPIC),* any contracted health care providers, administrators, or other associated parties on the other hand, for alleged violation of any duty arising out of or related to membership in KFHP or coverage by KPIC, including any claim for medical or hospital malpractice (a claim that medical services were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered), for premises liability, or relating to the coverage for, or delivery of, services or items, irrespective of legal theory, must be decided by binding arbitration under California law and not by lawsuit or resort to court process, except as applicable law provides for judicial review of arbitration proceedings. I agree to give up our right to a jury trial and accept the use of binding arbitration. I understand that the full arbitration provision is contained in the Evidence of Coverage and in the Certificate of Insurance.
Employee name (please print)*
Date*

MonthDayYear
Date
Signature*

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*Disputes arising from any of the following KPIC products are not subject to binding arbitration: 1) Tiers 2 & 3 of the Point-of-Service (POS) Plan; 2) the Preferred Provider Organization (PPO) and Out-of-Area Indemnity (OOA) Plans; and 3) the KPIC Dental plans.
E FAMILY INFORMATION (additional dependents)

SpouseDomestic partner
Date of birth (mm/dd/yyyy)

MonthDayYear
Date
Gender

MF
Social Security number
Name (Last, First, MI)
Medical record number (if known)
Dependent
Date of birth (mm/dd/yyyy)

MonthDayYear
Date
Gender

MF
Social Security number
Name (Last, First, MI)
Medical record number (if known)
Dependent
Date of birth (mm/dd/yyyy)

MonthDayYear
Date
Gender

MF
Social Security number
Name (Last, First, MI)
Medical record number (if known)
Name (Last, First, MI)

Dependent
Date of birth (mm/dd/yyyy)

MonthDayYear
Date
Gender

MF
Social Security number
Name (Last, First, MI)
Medical record number (if known)
Should be Empty:

EMPLOYEE ENROLLMENT

EMPLOYEE ENROLLMENT

B TO BE COMPLETED BY EMPLOYEE

EMPLOYEE ENROLLMENT

D SIGNATURE