Kaiser Permanente

Enrollment Application/Change Form

A. Enrollment (check one)
__New Hire Enrollment
__Open Enrollment
__Marriage Addition
__Newborn Addition
Other_______________________________
Event Date___/___/____

B. Change (check one)
__Delete Dependent(s)
__Address Change
__Name Change
Other_______________________________
Event Date___/___/____

C. Name Change
From____________________    __________________________ to____________________    __________________________
              Last Name                                      First Name                                          Last Name                                  First Name

D. About You (Subscriber)
Social Security Number:_____ - _____ - _____
Last Name: ____________________
First Name: ___________________
Middle Initial: ___
Date of Birth: ___/___/___
Gender: __M or __F
Marital Status: __Married or __Single
Maiden Name(if applicable):____________________
Language Spoken:_________________
Language Written:_________________
Street Address:________________________________________________________
City:____________________
State:___________________
Zip Code:________________
Day Phone:(___)____-______
Evening Phone:(___)____-_____
Have you ever been a member or received care from Kaiser permanente within the state of California?__Yes or __No
What is your Medical Record Number (from your ID Card)?____________________________

E. About Your Employment
Company Name:__________________________________
City:__________________________________________
Date of Hire:___/___/_____
Employee Number:______________
Employment Status: __Working or __Retired

F. About Your Family (Previous Kaiser Foundation Health Plan members should list all previous Medical Record Numbers below(if known)):

Last Name First Name MI Social Security Number Date of Birth Sex Add/Delete Medical Record # if known

Spouse:_______________

 ____________ ___ ______-_____-______  ___/___/___ M__/F__ Add__/Delete__ _________________
Dependent:_____________ ____________ ___ ______-_____-______ ___/___/___ M__/F__ Add__/Delete__ _________________
Dependent:_____________ ____________ ___ ______-_____-______ ___/___/___ M__/F__ Add__/Delete__ _________________
Dependent:_____________ ____________ ___ ______-_____-______ ___/___/___ M__/F__ Add__/Delete__ _________________
Dependent:_____________ ____________ ___ ______-_____-______ ___/___/___ M__/F__ Add__/Delete__ _________________


Dependent's Address (If different from subscriber) __Check here if all dependents are at address below
Name(s):____________________________________
Address:____________________________________
City:_________________________________
State:_________________________________
Zip Code:___________________________
I understand that, except for small claims court cases and claims subject to the Medicare Appeals Procedure, any claim that I, my heirs, or other claiments associated with me assert for alleged violation of any duty arising out of or relating to membership in Health Plan, including and claim for medical or hospital malpractice, for premises liability, or relating to the coverage for, or delivery of, services or items, irrespective or 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. I agree to give up my right to a jury trial and accept the use of a binding arbitration. I understand that the complete arbitration provision is contained in Evidence of Coverage.
Subscriber's Signature:_________________________________________
Date:_______/_____/______