To make sure all steps are completed we recommend that you Print this page.

You can also download and print the application and medical questionnaire (An application will need to be filled out for each family member enrolling). You will need the free Adobe Acrobat Reader to view this file.

1. Use a black or blue ink pen to complete the application and questionnaire for yourself and/or family members. Do not use a photocopy of the form. Be sure to answer all questions carefully and accurately for all members applying. Application and questionnaire must be completed and submitted by the applicant, or parent or guardian for children under 18. Spouses and dependent children under age 21 and dependent children who are full-time students under age 23 are eligible for coverage. Note: Please provide date of last menstrual period for all applicants between ages 12 - 55.
    

 
2. Each family member must complete an application.
    
3. Please mail the completed forms to:
   
   GORDON PAUL
   Kaiser Permanente Personal Advantage Plan
   1368 W. Herndon Avenue, Suite 101
   Fresno, CA 93711
   
   
4. Or Fax completed forms to:
   
   1-559-431-0009
   
   
5. We will review your application upon receipt. To avoid processing delays, your application information must be completed in full. Be sure to sign and date the application. If we have no questions from this review, you can expect a written decision of your membership status within two weeks.
    
6. Do not cancel your current coverage. Receipt of your application does not imply acceptance. Kaiser Permanente will notify you by mail upon acceptance.

All applications are subject to medical review. Each applicant will be accepted or denied based on medical information supplied in their application and medical questionnaire.