Get Group Enrollment Request Form

Completing the Group Enrollment Request Form is an essential step to become a member of the Kaiser Permanente Senior Advantage plan. This guide will provide you with clear instructions on how to fill out the form accurately and efficiently online.

Follow the steps to complete the Group Enrollment Request Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Carefully read all instructions on the form before beginning. This ensures that you understand the requirements and the necessary fields.
3. Separate the pages along the perforated edge before filling out the form. Ensure that you only work with the individual pages as instructed.
4. Provide necessary personal information, including your name, contact details, birth date, and sex. Ensure that this information matches your official identification documents.
5. Complete the Medicare insurance information section by filling out details that match your Medicare card. If needed, attach a copy of your Medicare card.
6. Answer all questions regarding employment status, coverage preferences, and other relevant details regarding your healthcare scenario to ensure accurate processing.
7. Read the arbitration agreement carefully and sign at the bottom of the form. This confirms your understanding and agreement with the terms outlined.
8. After completing the form, save your changes and download a copy for your records.
9. Print out the original signed form and prepare to mail it using the enclosed postage-paid envelope to the designated address.
10. Keep a copy of the completed form for your personal records and submit the necessary copies to your employer group or trust fund as required.

Take action now and complete your Group Enrollment Request Form online!