Get Kaiser Declination Of Coverage Form

Filling out the Kaiser Declination Of Coverage Form online is an important step for individuals who choose not to enroll in Kaiser Permanente's health coverage. This guide provides clear instructions to help you complete the form accurately and efficiently.

Follow the steps to complete your declination form online.

1. Click ‘Get Form’ button to obtain the form and access it for filling out.
2. Enter your employee name in the designated field. Ensure that the name is printed clearly.
3. Provide your company's information, including the company name and customer ID if one has been assigned.
4. Fill in the street address of your workplace, avoiding the use of P.O. boxes.
5. Enter your office phone number, including the extension if applicable.
6. Input the city, state, and ZIP code associated with your company's address.
7. Select the reason for declining coverage by checking the appropriate box that corresponds to your situation.
8. If applicable, write the name of the carrier for the health plan you are currently enrolled in. This could be another employer's health plan, an individual health plan, Medicare, etc.
9. Print your name again in the signature section, along with the last four digits of your Social Security number.
10. Sign and date the form, ensuring that the signature is clear and matches the printed name.
11. After completing the form, you can save your changes, download a copy, print it out, or share it as necessary.

Begin filling out your Kaiser Declination Of Coverage Form online today!