Get California Enrollment/change Form - Kaiser Permanente - Brokernet Kp

This guide will provide you with a comprehensive understanding of how to complete the California Enrollment/Change Form for Kaiser Permanente online. Follow the instructions carefully to ensure accurate submission of your enrollment or change request.

Follow the steps to fill out the form accurately.

1. Click ‘Get Form’ button to obtain the California Enrollment/Change Form. This will allow you to access the form in an editable format.
2. Begin by completing the section labeled 'To be completed by employer.' This includes entering the company name, hire date, group number, and effective enrollment/change date.
3. Move to Section A, 'Enrollment/Change Reason.' Indicate your reason for enrollment or change, such as new hire, open enrollment, or loss of other coverage, by checking the appropriate option. If necessary, provide additional details.
4. In Section B, you will provide personal information as the employee, including your past experience with Kaiser Permanente, medical record number, birth date, social security number, and contact details such as home and work phone numbers.
5. Proceed to Section C, which is dedicated to enrolling or deleting dependents. Indicate their names, relationship to you, birth dates, and social security numbers, as well as mark whether they are being added or deleted.
6. Section D requires your signature and the date. Ensure that you also provide the employer's signature and date at the bottom of the form.
7. Once all sections are completed, make a copy for your records. This will serve as a temporary ID card until your enrollment is processed.
8. Finally, save any changes made to the form, and if you need to, download, print, or share the completed form as necessary.

Complete your California Enrollment/Change Form online today to ensure your enrollment or changes are processed efficiently.