Apply On-Line
You have the option of Applying Online or mailing your application using the instructions below.
Apply By Mail
To apply by mail or fax please follow the following instructions:
To make sure all steps are completed we recommend that you Print this page.
You will need the free
Adobe Acrobat Reader to read these files. You will not be
able to submit these forms via the Internetyou must print the forms, complete them and
mail them to the address below.
- Complete the
Application.
- Answer all questions completely and accurately.
- Print, sign, and date the questionnaire.
- Remember to select the benefit plan of your choice.
- Include the first month's premium.
- Premiums are based on the oldest
person in the family unit applying for coverage.
- No forms will be reviewed without the
premium.
- If you pay by check, please return the completed form to:
GORDON PAUL
Kaiser Permanente Personal Advantage Plan
1368 W. Herndon Avenue, Suite 101
Fresno, CA 93711
- If you pay by credit card, please enter the credit card information on the form and you may fax the completed application to
1-559-431-0009 Fax
or you mail mail it to the address above (#2).
Reminder: All questions must be
answered and all forms submitted along with the first month's premium to
begin the underwriting process. Unanswered questions and/or incomplete
forms will result in the application being returned to you.
It will take a full 21 business
days, once we receive your application, for a decision regarding your
individual membership coverage. You will receive written notification
regarding the outcome of our review.
HEALTH INSURANCE
PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)
Eligibility Guidelines
| You are applying for health insurance
coverage that is subject to medical underwriting. If you
believe that you are HIPAA eligible and have indicated that on your
application and if you are denied for the medically underwritten plan,
your application will automatically be sent to our HIPAA Department
for review. You may be contacted for further information or
verification. The Health
Insurance Portability and Accountability Act was signed by President
Clinton in 1996. A significant portion of the law is intended to reduce
barriers for Eligible Individuals to obtain health insurance
coverage through an individual plan.
Health plan carriers serving the
individual market must offer coverage to an eligible individual and may
not impose any preexisting condition exclusions with respect to such
coverage.
An Eligible Individual is a person
who:
- has had at least 18 months of
aggregate Creditable Coverage;
- has been under a group health plan, a
governmental plan, or church plan (or health insurance offered in
connection with such plans) during the most recent period of creditable
coverage;
- is not eligible for coverage under a
group health plan, Medicare, or Medicaid, and does not have other
health insurance coverage;
- has not had their most recent coverage
canceled for nonpayment of premiums or fraud; and
- has elected and exhausted any
option for continuation of coverage ("COBRA" coverage) that was
available under the prior plan.
Creditable Coverage means coverage
under any of the following:
- A group health plan;
- Health insurance coverage;
- Part A or B of Title XVIII of the
Social Security Act (U.S.C. 1395c or 1395);
- Title XIX of the Social Security Act
(42 U.S.C. 1396 et seq.), other than coverage consisting solely of
benefits under section 1928;
- Chapter 55 of Title 10, United States
Code (10 U.S.C. 1071 et seq.);
- A medical care program of the Indian
Health Service or of a tribal organization;
- A state health benefits risk pool;
- A health plan offered under Chapter 89
of Title 5, United States Code (5 U.S.C. 8901 et seq.);
- A public health plan (as defined in
federal regulations); or
- A health benefit plan under section 5
(e) of the Peace Corps Act (22 U.S.C. 2504(e)).
If you are an Eligible Individual and
would like to apply for such coverage, please call (301) 816-6700 for an
enrollment kit. If you already have an enrollment kit, mail your signed
and completed application along with your Certificate of Credible Coverage
in the enclosed business reply envelope. |
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