CA Kaiser Permanente Subscriber Enrollment/Change Form 2020-2025 free printable template
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Kaiser Permanent
California Subscriber Enrollment/Change Form
Instructions for FEB Program Enrolled
Who should use Federal Employees Health Benefits (FEB) Program enrolled in Kaiser Permanents
California
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How to fill out CA Kaiser Permanente Subscriber EnrollmentChange Form
How to fill out CA Kaiser Permanente Subscriber Enrollment/Change Form
01
Obtain the CA Kaiser Permanente Subscriber Enrollment/Change Form from the Kaiser Permanente website or your local office.
02
Fill out the personal information section at the top of the form, including your name, address, and contact information.
03
Indicate whether you are enrolling, changing, or canceling coverage by checking the appropriate box.
04
Provide your social security number and date of birth as required.
05
Complete the section regarding dependents by listing any family members you wish to add to your coverage.
06
Select your desired plan options from the choices provided on the form.
07
Review the information for accuracy and completeness.
08
Sign and date the form to certify that the information is true and correct.
09
Submit the completed form to Kaiser Permanente via the submission methods outlined on the form (mail, fax, or online submission).
Who needs CA Kaiser Permanente Subscriber Enrollment/Change Form?
01
Individuals who are seeking to enroll in or make changes to their Kaiser Permanente health insurance plan.
02
Current subscribers needing to update personal information or change coverage options.
03
New members who want to establish coverage through Kaiser Permanente.
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What is CA Kaiser Permanente Subscriber Enrollment/Change Form?
The CA Kaiser Permanente Subscriber Enrollment/Change Form is a document used to enroll in or make changes to a Kaiser Permanente health insurance plan in California.
Who is required to file CA Kaiser Permanente Subscriber Enrollment/Change Form?
Individuals who wish to enroll in Kaiser Permanente health plans or make changes to their existing enrollment, such as adding dependents or updating personal information, are required to file this form.
How to fill out CA Kaiser Permanente Subscriber Enrollment/Change Form?
To fill out the CA Kaiser Permanente Subscriber Enrollment/Change Form, provide required personal information, select the desired health plan, indicate any changes, and ensure all sections are completed accurately before submitting.
What is the purpose of CA Kaiser Permanente Subscriber Enrollment/Change Form?
The purpose of the CA Kaiser Permanente Subscriber Enrollment/Change Form is to facilitate the enrollment process for new members and to allow current members to make necessary changes to their health insurance coverage.
What information must be reported on CA Kaiser Permanente Subscriber Enrollment/Change Form?
The form requires personal details such as name, address, date of birth, social security number, and details about dependents, as well as the selection of the health plan and any specific changes being requested.
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