Get Kaiser Permanente Group Election Request Form - Fhdafiles Fhda

Filling out the Kaiser Permanente Group Election Request Form is an essential step toward becoming a member of the Senior Advantage program. This guide provides clear and supportive instructions to help individuals complete the form accurately and efficiently online.

Follow the steps to fill out your form online.

1. Click the ‘Get Form’ button to access the Kaiser Permanente Group Election Request Form and open it in your preferred editor.
2. Begin by filling out your personal information, including your last name, first name, middle initial, home phone number, alternate phone number, date of birth, and sex. Complete these fields carefully, ensuring that all information matches your identification documents.
3. Provide your permanent residence address, avoiding the use of a P.O. Box. If your mailing address differs from your residence address, include that information in the specified fields.
4. Fill in your Medicare insurance information. You may either enter the details as seen on your Medicare card or attach a copy of the card to the form.
5. Respond to the important questions outlined in the form, such as your current or former membership status with any Kaiser Permanente health plan, work status, and details regarding end-stage renal disease, if applicable.
6. Specify any existing prescription drug coverage along with the relevant identification numbers, if you have any.
7. Indicate your requested effective date for coverage and ensure that it is subject to approval by CMS.
8. Read and understand the arbitration agreement. Sign and date the form to confirm that you agree to the terms laid out in the document.
9. Make a copy of the completed form for your records. Then, print, sign, and mail the original signed form using the enclosed postage-paid envelope to the Kaiser Permanente Medicare Unit.
10. Once submitted, keep an eye on your mail for confirmation from Kaiser Permanente regarding the completion of your application and the effective date of your coverage.

Begin filling out your Kaiser Permanente Group Election Request Form online today.