Get 2015 Kpsa Group Enrollment Form - California - Optum Fillable - Gcccd

Filling out the 2015 KPSA Group Enrollment Form is your first step towards becoming a Kaiser Permanente Senior Advantage member. This guide provides clear instructions to help you successfully complete the form online.

Follow the steps to efficiently and accurately complete the enrollment form.

1. Click 'Get Form' button to access the enrollment form and open it in your editor.
2. Begin by removing the perforated tab at the top of the page to separate it from the original document.
3. Next, ensure all pages are separated before filling out the form to maintain clarity.
4. Provide your personal information in the designated fields, including your last name, first name, middle initial, birth date, and contact numbers.
5. Indicate your current or former membership status with any Kaiser Permanente health plans, if applicable.
6. Fill in your permanent residence address and ensure that a P.O. Box is not used.
7. Complete the Medicare insurance section by matching the details to your Medicare card or attaching a copy of it.
8. Answer the important questions about employment status, retiree coverage, and whether you have other drug coverage.
9. Select your preferred effective date and language format for communication if applicable.
10. Review the arbitration agreement and sign the form, indicating your understanding and agreement to the terms.
11. Finally, save your changes, download a copy for your records, and submit the original signed form as instructed.

Start completing your forms online today for a smoother enrollment experience.