Get Retroactive Membership Request Form

Filling out the Retroactive Membership Request Form is an important step in requesting retroactive changes to your Kaiser Permanente membership. This guide will provide you with a clear, step-by-step approach to completing the form online, ensuring that you provide all necessary information accurately.

Follow the steps to complete the Retroactive Membership Request Form

1. Click ‘Get Form’ button to access the Retroactive Membership Request Form and open it in your preferred document editor.
2. Enter your purchaser information in Section One. Include the date, your purchaser number, and the full name and contact information. Be sure to indicate whether you are a KPIC purchaser and list the plan type if applicable. Also, provide answers to the payment and retroactive inquiries as necessary.
3. In Section Two, fill in the member information section. This includes the employee's name and social security number (SSN), as well as the dependent name if applicable. If additional space is needed, use the provided continuation page.
4. Complete Section Three by providing your signature and the date. Ensure you understand the conditions outlined regarding Kaiser Permanente’s retroactivity request policy. The form will not be processed without this signature.
5. Attach any supporting documentation that substantiates your request for retroactive membership changes. It's important that all documents are accurate and complete to prevent delays.
6. Finally, review all information for accuracy before submission. When ready, save any changes made to the form. You can then opt to download, print, or share the completed form with your Account Administration Representative.

Complete your Retroactive Membership Request Form online today for an efficient processing experience.