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The document is a California Region Group Enrollment/Change Form used for enrolling or making changes to health plan coverage with Kaiser Permanente. It includes sections for employer and employee information, reasons for enrollment or change, family member details, and an arbitration agreement. The form requires specific instructions to be followed for completion and emphasizes the importance of accurate information for effective enrollment.

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Versions	Form popularity	Fillable & printable
2011	4.9 Satisfied (59 Votes)
2008	4 Satisfied (23 Votes)

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Does Kaiser send out 1095 forms?

Employees who have Kaiser insurance will receive the 1095 directly from Kaiser. 1095 forms will be available online through the members Kaiser Permanente account. To request a paper copy, please contact member services at 877.514. 5114.

How do I change my name at Kaiser?

For updates to your personal information or demographics (name, address, date of birth, etc.) please contact our member services department at 1-800-464-4000 they will be able to guide you through this process.

How to request to correct or amend Kaiser Permanente health information?

please contact our member services department at 1-800-464-4000 they will be able to guide you through this process. To submit a request to amend or correct information in your medical record, please complete the patient amendment request form below: Patient Amendment Request - English (PDF)

How do I request a medical record correction?

The patients request must be in writing and must be signed and dated. (Notify the patient that the request will become part of the permanent record.) The request must be directed to the provider who originated the portion of the record the patient wants to amend.

How long does Kaiser Permanente keep medical records?

CMS requires Medicare managed program providers to retain medical records for 10 years. Kaiser Permanente follows CMS standards for medical records retention.

kaiser permanente enrollment form

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How do I dispute my Kaiser medical bill?

To inquire about filing a payment dispute and/or the status of previously submitted disputes, contact KP through Online Affiliate or by calling: (800) 390-3510.

How to do a name change with Kaiser?

Send a message to Member Services with the subject other. To change your name, date of birth, Social Security Number, or gender: Complete an Account Change Form (available below) and follow the instructions. Note: Updating your address or date of birth may cause your plan rates to change.

How do I change my Kaiser Permanente plan?

You can fill out and send in an Account Change Form. If required, youll need to provide proof of your qualifying life event and fill out and send in our Proof of qualifying life event form.