Employee Dependent Change form - Kaiser Permanente Brokers 2026

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The document is an application form for Kaiser Permanente's Individual and Family Plans (KPIF) health coverage. It outlines eligibility criteria, instructions for completing the application, and details on how to apply during open or special enrollment periods. It specifies who should not use the application, such as those eligible for Medicare or seeking federal financial assistance. The document also includes sections for personal information, health plan selection, optional dental coverage, payment details, and grievance procedures related to discrimination.
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  1. Click 'Get Form' to open the Employee Dependent Change form in the editor.
  2. Begin by selecting your application type: either 'Open enrollment' or 'Special enrollment period'. If you choose special enrollment, specify the qualifying life event.
  3. In Step 2, select your desired health plan from the options provided. Ensure that all family members applying for different plans submit separate applications.
  4. Fill in your personal information in Step 4. This includes your name, Social Security number, date of birth, and contact details. Make sure to provide accurate information for all dependents.
  5. If applicable, designate an authorized representative in Step 5 by providing their name and contact information.
  6. Sign the application agreement in Step 6. All applicants aged 18 and older must sign this section.
  7. Complete payment details in Step 8. Choose your payment method and provide necessary information for processing.

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Start by signing in to kp.org and then go to Act for a Family Member. Youll need your dependents full name, date of birth, and Medical Record number. Under People youre taking care of, select Add a child/teen to your family list and follow the instructions.
You are vested in the plan after 5 years of service. You may be eligible for retiree health and insurance benefits when you retire, depending on your age and years of service at retirement. You may purchase more benefits and services at group rates.
A Kaiser Permanente California plan. This is a Medicare Advantage plan, which means that it generally replaces your Medicare coverage. You agree to let Kaiser manage your Medicare benefits. It is an HMO (health maintenance organization) with a closed network of providers.
Depending on your position, your compensation and benefits may include: Generous Vacation, Holiday Sick Leave. Medical (including prescriptions), Vision, Mental Health Dental Care. Disability Life Insurance Coverage.
Providers may request pre-certification by either: Calling Permanente Advantage at 1-888-567-6847; or. Completing the Permanente Advantage Pre-Certification Request Form and faxing to 1-866-338-0266.

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Kaiser Permanente has an overall rating of 3.8 out of 5, based on over 16,037 reviews left anonymously by employees. 71% of employees would recommend working at Kaiser Permanente to a friend and 62% have a positive outlook for the business. This rating has decreased by 1% over the last 12 months.
Generous Vacation, Holiday Sick Leave. Medical (including prescriptions), Vision, Mental Health Dental Care. Disability Life Insurance Coverage.

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