| | Kaiser Permanente Forms |
| | All forms and plan descriptions are in portable document format (PDF).
 |
| | Some forms are available for download in Spanish.
Click the language to download the form. |
| | Form Type: Medical |
| | Form Name | Form Description
|
| |
Affidavit of Common-Law Marriage
English
() | Request for enrollment of common-law spouse. |
| |
Application / Change Form
English
(231 kb) | Use this form for Enrollment/Open Enrollment, Change of Information, and Cancellation of Coverage |
| |
Broker's Step-by-Step HSA Guide
English
(106 kb) | Establish a Wells Fargo HSA for Employer Clients |
| |
Business group of one enrollment requirements
English
() | Business group of one enrollment requirements |
| |
Colorado Purchaser Application
English
() | For use when employees reside outside of Kaiser's service area (OOA). |
| |
COLORADO UNIFORM EMPLOYEE APPLICATION
English
Spanish
() | This form is designed for an employee’s initial application for coverage. |
| |
Conversion Application - Age Rated
English
(681 kb) | Use this form to convert your current plan coverage to a Standard or Basic Health benefit plan. |
| |
Domestic Partnership Alternative Affidavit
English
() | Domestic Partnership Alternative Affidavit |
| |
Domestic Partnership Cohabitation Declaration
English
() | Domestic Partnership Cohabitation Declaration |
| |
Employee Guide - CarePay(sm) HSA Guide
English
(791 kb) | CarePay HSA Benefits and Advantages Guide |
| |
Employee Manual for Plans with HSA Options
English
(908 kb) | Employee's Guide to HSA Health Plans; including Plan Benefits Descriptions, and Tax Advantages |
| |
Employer Application - HSA Account
English
(65 kb) | Application for HSA Account Set-up with Wells Fargo |
| |
Employer HSA Implementation Guide
English
(467 kb) | Employer Guide to HSA Setup, Enrollment, etc to CarePay(sm) Health Savings Accounts |
| |
Enrollment Waiver
English
(17 kb) | Employee's Form to decline the Kaiser Permanente enrollment opportunuty, with for self and eligible dependents, or eligible dependents only-
Please use page Two Of this Uniform Application to waive- |
| |
HRA application form
English
() | Health reimbursement arrangement (HRA) application form |
| |
HSA Broker Supplement Application for Proposals and New Subscribers
English
(21 kb) | HSA Broker Supplement Application for Proposals and New Subscribers |
| |
HSA Enrollment Form for Employees
English
(95 kb) | HSA Enrollment Form for Employees |
| |
HSA Plans - FAQs
English
(384 kb) | Answers to many Frequently Asked Question regarding HSA Plans. |
| |
Kaiser Plan Pairings Grid 2008-09
English
() | Kaiser medical plan pairing |
| |
Kaiser Small Group Plan Combinations 2008
English
() | Small Group Plan Combinations for Kaiser 2008 |
| |
PREVIOUS HEALTH BENEFIT COVERAGE AFFIDAVIT
English
() | Have you sponsored a health benefit plan for your employees during the past 12 months? |
| |
SG_PlanComboTool Layout
English
() | Kaiser's New Plan Pairing Layout |
| |
Small business group 2-50 requirements
English
() | Small business group 2-50 employees enrollment requirements |
| |
Small Business Group Application
English
(113 kb) | Small Business Group Application |
| |
Small Group Employee Census Information
English
() | Small Group Employee Census Information |
| |
Student Verification Form
English
(81 kb) | Use this form to verify dependents 19 or older meet eligibility requirements to continue coverage |
| |
TERMINATION OF DOMESTIC PARTNERSHIP
English
() | STATEMENT OF TERMINATION OF AFFIDAVIT OF DOMESTIC PARTNERSHIP |
| |
