Get Kaiser Permanente Disabled Dependent Enrollment Application 2006
How it works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
How to fill out the Kaiser Permanente Disabled Dependent Enrollment Application online
This guide is designed to assist you in completing the Kaiser Permanente Disabled Dependent Enrollment Application quickly and accurately. By following the steps outlined below, you can ensure that your application is filled out correctly and submitted without any issues.
Follow the steps to complete the enrollment application.
- Click ‘Get Form’ button to obtain the Kaiser Permanente Disabled Dependent Enrollment Application and open it for editing.
- Fill in your information as the subscriber. This includes entering your last name, first name, middle initial, address, telephone number, social security number, Kaiser Permanente medical record number, group number, and your employer's name and telephone number.
- Enter your dependent's information. Provide their last name, first name, middle initial, address, telephone number, social security number, Kaiser Permanente medical record number, birthdate, and your relationship to them.
- Designate the practitioner overseeing the dependent's care by entering the physician’s name and their office location details, including telephone number and address.
- Complete the Subscriber Questionnaire section. Circle 'Yes' or 'No' for each statement regarding your dependent's enrollment, need for support, tax status, aid received, work status, living arrangements, school attendance, and provide any additional information as necessary.
- Have a Kaiser Permanente physician or an outside physician fill out Part B, providing details about the dependent’s medical condition and outline any limitations they may experience.
- Attach all required supporting documents as directed, including proof of living expenses, a page of your tax return that lists your dependent, and any additional required documentation.
- Review the application for completeness and accuracy before submitting. Make sure all signatures are secured, including the Statement of Authorized Representative if applicable.
- Once everything is completed, follow the instructions provided to submit the application either by mail or fax.
- You can save changes, download, print, or share the form as needed.
Start filling out the Kaiser Permanente Disabled Dependent Enrollment Application online today to ensure timely processing.
Get form
Related links form
Dependents of Kaiser Permanente typically include your spouse and children. They might also encompass other individuals who meet specific eligibility criteria, such as those with disabilities. Understanding your dependents is crucial, especially when completing the Kaiser Permanente Disabled Dependent Enrollment Application to ensure everyone receives proper coverage.
Get This Form Now!
Industry-leading security and compliance
-
In businnes since 199725+ years providing professional legal documents.
-
Accredited businessGuarantees that a business meets BBB accreditation standards in the US and Canada.
-
Secured by BraintreeValidated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.