Kaiser Permanente Continuation of Coverage Form

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KAISER
REQUEST FOR CONTINUATION OF COVERAGE

STEP 1:

I have been informed by my employer of the three options available to me relating to continuing Kaiser Foundation Health Plan coverage. I have read about the options and I am choosing the one indicated below:

Please check one:
( ) 1. To continue my group coverage. (Applies to COBRA affected groups only)
( ) 2. To convert my group coverage to Kaiser Individual Plan.
( ) 3. To discontinue all health plan coverage with Kaiser.

STEP 2:

Person who wishes to receive information:

______________________________________________________________________ Name sex dob
______________________________________________________________________ Address
______________________________________________________________________ City State Zip
______________________________________________________________________ Daytime Phone Evening Phone
______________________________________________________________________ Social Security No.
______________________________________________________________________ Account No.
______________________________________________________________________ Employee's Name (If different from above)

STEP 3:

Continuation Coverage should be offered to:
( ) All enrolled family members OR ( ) Only these members:
Name _________________________________________________________________ sex dob
Address ______________________________________________________________
Kaiser Medical Record No. ____________________________________________
Relationship to Employee _____________________________________________

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Name _________________________________________________________________ sex dob
Address ______________________________________________________________
Kaiser Medical Record No. ____________________________________________
Relationship to Employee _____________________________________________

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Name _________________________________________________________________ sex dob
Address ______________________________________________________________
Kaiser Medical Record No. ____________________________________________
Relationship to Employee _____________________________________________

STEP 4:

Reason for Request (Please check)
( ) 1. Termination from employment, date ______________________________
( ) 2. Reduction of employment hours, date_____________________________
( ) 3. Retirement, date________________________________________________
( ) 4. Marriage of covered child named below on (date)
________________________________________________________________
( ) 5. Dependent reached age limit, date_______________________________
( ) 6. Divorce or legal separation, date_______________________________
( ) 7. Death of Subscriber, date_______________________________________
( ) 8. No longer eligible, please convert to Individual Plan

STEP 5:

I apply for Health Plan membership for myself and my covered family dependents. We agree to abide by the provisions of the Service Agreement and Health Plan policies. We understand that, except for small claims court cases, any claim that we, our heirs, or other claimants associated with us, assert for alleged violation of any duty arising out of or relating to the Service Agreement, including any claim for medical or hospital malpractice, for premises liability, or relating to the coverage for, or delivery of, service pursuant to the Agreement, irrespective of legal theory, must be decided by binding arbitration under California law and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. We are therefore giving up our right to a jury trial and are accepting the use of binding arbitration.

______________________________________________ ________________________ Signature of Person Making this Request Today's Date

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STEP 6:

Employer/Group Use Only Kaiser Use Only

Group Name________________________ ABI/GA____________________
Group No. ____________________________________________________
Subgroup No.__________________________________________________
Group authorizing signature___________________________________

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