Kaiser Permanente Forms

California Group Coverage Forms
Please return completed forms by faxing them to 1-559-431-0009.

Enrollment Forms

  1. New Group Application(English)
  2. Employee Enrollment Application
  3. Proprietor/Partnership/Corporate Officer Form
  4. Declination of Coverage
  5. New Employee Eligibility Documentation
  6. Authorization for Initial Payment by Electronic Transfer
  7. Temporary Member ID

Administration Forms

  1. Address Change Form
  2. Account Change Form
  3. Employee Termination Report
      Complete this form to show terminations to your account.
  4. Kaiser Representative Assignment Form