Get California Enrollment Form

Filling out the California Enrollment Form is a crucial step for individuals seeking to enroll in a health plan. This guide provides clear and supportive instructions to help users navigate the form efficiently.

Follow the steps to complete the California Enrollment Form online.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred document editor.
2. Begin by filling out the employer section. Enter the company name, hire date (in mm/dd/yyyy format), group number, and effective enrollment/change date.
3. Select the reason for enrollment or change in section A. Choose from options such as 'New Hire', 'Open Enrollment', 'Loss of Other Coverage', 'Name Change', and specify if it is a new group.
4. In section B, provide the employee details. Answer whether you have been a Kaiser Permanente member before, and fill in your medical record number (if known), social security number, name, birth date, home address, and contact information.
5. In section C, list any family members or dependents. For each individual, indicate if you want to add or delete them, their gender, social security number, name, birth date, relationship, and any other relevant details. If needed, attach an additional sheet.
6. Complete section D by reading and signing the Kaiser Foundation Health Plan Arbitration Agreement. Ensure that you date the form appropriately.
7. After completing the form, ensure you save your changes. You can then download, print, or share the form as needed. It is advisable to make a copy for your records.

Start filling out the California Enrollment Form online today to ensure timely enrollment in your health plan.