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PAGE 1 OF 6 Kaiser Permanent for Individuals and Families Membership Application Instructions: You must fully answer each question in this application even though you may already be a Kaiser Foundation

The application should not be used for any other purpose. To get an application, go to. Go to the Health Care Coverage page. Choose the “Application for a health plan” link. Complete all required fields. Click on “I agree” to download the Application for a Kaiser Permanent membership Form, which you must mail to Kaiser Permanent. (A one-time membership fee of 15 is included.) The form is a 10-page paper and must be completed and returned with your enrollment application form. If you plan to return a copy of the enrollment form to me, please include this form. Be sure to mail your application form by check, money order, or money transfer, to Kaiser Permanent, P.O. Box 89904 Sacramento, CA 94. Please be sure to include the following items on the enrollment form: Current address and phone number. Name, address, and date of birth. Social Security Number (SSN) if applying for an individual Kaiser policyholder (KM). Health Plan Identification Number (ICN), if applying for an individual Kaiser Primary Care Provider (PCP). A 4 non-refundable fee has been waived for your enrollment. The enrollment processing fee is paid to the California Health Benefit Exchange for the Department of Consumer Affairs and will be deducted from your KPF member account. Please be sure to include the following items on the enrollment form: How long are you and your family expecting to be in Oregon? How many people do you expect to join your household? State or country of residency? Country of birth? Citizenship? How old are you? State you were or are a U.S. citizen? Current Employer Information (for spouses): For spouses only: U.S. or foreign income State you were or are a resident of Current Employer Information (for children and dependent individuals): If you have a child or dependents who are on your plan, please also provide the date each person's coverage began and ended, as well as the type of coverage each person is receiving and the amount of each person's premiums. If you are applying for an Individual Family Policy or Multiple Coverage Option: If you are applying for an Individual Family Policy (FOP) or Your Child Will Get It (UCC).

For pdfFiller’s FAQs

What is kaiser permanente for individuals?

Kaiser Permanente for individuals is a health insurance plan provided by Kaiser Permanente specifically designed for individuals and families who do not receive health insurance coverage through their employers or government programs.

Who is required to file kaiser permanente for individuals?

Individuals and families who do not receive health insurance coverage through their employers or government programs are required to file for Kaiser Permanente for individuals.

How to fill out kaiser permanente for individuals?

To fill out Kaiser Permanente for individuals, you can visit the official website of Kaiser Permanente or contact their customer service for assistance. They will guide you through the application process and provide you with the necessary forms and instructions.

What is the purpose of kaiser permanente for individuals?

The purpose of Kaiser Permanente for individuals is to provide affordable and comprehensive health insurance coverage to individuals and families who do not have access to employer-sponsored or government-provided health insurance programs.

What information must be reported on kaiser permanente for individuals?

The information that must be reported on Kaiser Permanente for individuals includes personal details such as name, address, contact information, as well as information about your family members, income, and any pre-existing medical conditions.

When is the deadline to file kaiser permanente for individuals in 2023?

The deadline to file Kaiser Permanente for individuals in 2023 has not been specified. It is recommended to visit the official website of Kaiser Permanente or contact their customer service for the most accurate and up-to-date information regarding deadlines.

What is the penalty for the late filing of kaiser permanente for individuals?

The penalty for the late filing of Kaiser Permanente for individuals may vary depending on the specific circumstances and regulations. It is best to consult with Kaiser Permanente or refer to the official guidelines to understand the penalties associated with late filing.

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