Get Broker Direct Deposit Form - Kaiser Permanente Brokers And ...

This guide provides users with clear instructions on completing the Broker Direct Deposit Form for Kaiser Permanente Brokers online. By following these steps, you will ensure that your direct deposit information is accurately submitted and processed efficiently.

Follow the steps to effectively fill out the Broker Direct Deposit Form online.

1. Click the ‘Get Form’ button to access the Broker Direct Deposit Form and open it in your document editor.
2. Begin by filling out the required information in Section A. Include your first name, last name, and middle initial. Remember to indicate whether you are the subscriber, new subscriber, or the person responsible for payment.
3. If there are any changes to your address or phone number, check the appropriate box.
4. Provide your Social Security number if applicable, date of birth, and medical record number if available.
5. Enter your home and mailing addresses, ensuring P.O. boxes are not used. Specify the requested future effective date for your changes.
6. In Section B, select the changes you wish to make by checking the corresponding boxes. Be sure to indicate which family members are affected by these changes on the following page.
7. List all family members who are affected by the changes you selected, including their full names, Social Security numbers, dates of birth, and any additional required information.
8. In Section D, choose your new health plan from the list provided, ensuring that each selected plan is below your current plan.
9. Section E allows you to add or end optional dental coverage. Make your selections as applicable.
10. Section F requires signatures. Ensure all subscribers and dependents aged 18 and older sign and date appropriately.
11. Complete any additional required sections if there are more than two dependents affected.
12. Once you finish filling out the form, you can save your changes, download the completed form, print it, or share it online for submission.

Get started by downloading the Broker Direct Deposit Form online and follow the steps outlined above.