NOTE: Do NOT cancel your current coverage until notified that your application has been approved by underwriting.

Submitting an application DOES NOT Guarantee coverage. All applications are subject to medical review by the Kaiser Permanente underwriting department and will not be approved immediately. You will be notified upon approval by Kaiser Permanente and Insurance Now.
 

I hereby apply for membership in Kaiser Permanente based upon the following:
 

 

1. PERSONAL INFORMATION — PRIMARY APPLICANT
As the oldest person applying for coverage, I am the primary applicant and hereby apply for membership in Kaiser Permanente based on the following:

Select One: Mr. Mrs. Ms. Miss Dr.
Marital Status: Single Married Widowed Divorced
 
Last Name: First Name:   MI: Prior HRN*:
Social Security: Sex:   Birthdate:   Height: (ft/in) Weight: (lbs)
 
Street Address (cannot be a P.O. Box):   Apt.#
 
City:   State:   ZIP Code:
 
Home Phone:    Work Phone:   E-mail Address:
 
Is the billing address different than the address listed above?  Yes No
     Yes, please list the billing address below:
 
Billing Street Address:   Apt.# or P.O. Box
 
City:   State:   ZIP Code:
Please complete the following information for each additional person applying. If more space is needed for additional applicants, please attach another application and complete just the information for those additional applicants. (You can print another application from our Web site.
Spouse
Last Name: First Name:   MI: Prior HRN*:
Social Security: Sex:   Birthdate:   Height: (ft/in) Weight: (lbs)
 
Dependent 1 (D1)
Last Name: First Name:   MI: Prior HRN*:
Social Security: Sex:   Birthdate:   Height: (ft/in) Weight: (lbs)
 
Dependent 2 (D2)
Last Name: First Name:   MI: Prior HRN*:
Social Security: Sex:   Birthdate:   Height: (ft/in) Weight: (lbs)
 
Dependent 3 (D3)
Last Name: First Name:   MI: Prior HRN*:
Social Security: Sex:   Birthdate:   Height: (ft/in) Weight: (lbs)
 
Dependent 4 (D4)
Last Name: First Name:   MI: Prior HRN*:
Social Security: Sex:   Birthdate:   Height: (ft/in) Weight: (lbs)
 
Dependent 5 (D5)
Last Name: First Name:   MI: Prior HRN*:
Social Security: Sex:   Birthdate:   Height: (ft/in) Weight: (lbs)
 
Dependent 6 (D6)
Last Name: First Name:   MI: Prior HRN*:
Social Security: Sex:   Birthdate:   Height: (ft/in) Weight: (lbs)
 
Dependent 7 (D7)
Last Name: First Name:   MI: Prior HRN*:
Social Security: Sex:   Birthdate:   Height: (ft/in) Weight: (lbs)
 
Dependent 8 (D8)
Last Name: First Name:   MI: Prior HRN*:
Social Security: Sex:   Birthdate:   Height: (ft/in) Weight: (lbs)
 
   * Prior Kaiser Permanente Health Record Number (HRN), if applicable.
 
  2. PLAN SELECTION
  a) Which plan are you applying for?
   
 
  HMO Plans Custom Care HealthInvestor (HSA)
  Premier Plan HSA Option 3,500/100% Self HSA Option 3,500/100% Family
  Plan 500 HSA Option 5,000/100% Self HSA Option 5,000/100% Family
  Plan 1,000 HSA Option 3,500/80% Self HSA Option 3,500/80% Family
  Plan 2,000   HSA Option 5,000/80% Family
  Plan 3,000    
  Plan 5,000    
   
  Balance Plans
  If selecting one of the plan choices below, you are required to sign the acknowledgment form, found on the attached page. This acknowledgement form MUST be signed in order to apply for any of the plan choices listed below.
   
 
  Balance HMO Plans Balance HealthInvestor (HSA) Plans
  Balance HMO 2,000 Balance HMO 7,500 Balance HSA 1,200/100%
  Balance HMO 3,000 Balance HMO 10,000 Balance HSA 2,000/80%
  Balance HMO 5,000    
   
  b) Requested Effective Date of Coverage
 
The earliest your coverage will begin is the first of the month following receipt of a completed application and first month’s premium. Coverage will not be back-dated.
   
   
  What type of coverage are you applying for? (Select only one.)*
  Individual  Individual & Spouse Individual & Child(ren) Family (Individual, Spouse & Child[ren])
 
* If you are applying for a Kaiser Permanente Personal Advantage Balance plan, select “Individual” coverage. Each member of your family accepted for coverage will be enrolled in individual coverage. Dependent and family coverage are not available in the Balance plans.
 
Has any applicant ever been a Kaiser Permanente member? Yes No
If Yes, please be sure you have written their prior Kaiser Permanente Health Record Number (HRN), if known, in their “Prior HRN” box on the page 1.
  Type of Application:
  Addition of a family member to an existing Kaiser permanente member's coverage New coverage
     Existing member's Health Record Number (HRN)
   
   
  What if all family members are not accepted?
  Please remember that Kaiser Permanente’s Personal Advantage plans are individually underwritten. Each family member must pass a medical review. It is possible that some or all family members may not be accepted. In the event that all family members are not accepted, please instruct us how to handle accepted family members:
   
  Please enroll any accepted family members
 Please cancel the enrollment process for any accepted family members and return my first month's premium check
   
   
BALANCE PLAN ACKNOWLEDGEMENT FORM For

Balance Plan Applicants Only

If you are applying for a Kaiser Permanente Balance Plan, please read the following notice. If you are applying for any other type of plan, this notice does not apply, and you may simply disregard it.

In order to be enrolled in a Kaiser Permanente Balance Plan, you MUST sign the reverse side of this Balance Plan Acknowledgement Form and return it with this application. Failure to sign the form will delay your Kaiser Permanente enrollment.

Please also note that Balance plans offer individual coverage only. If your spouse and/or child(ren) would like to be enrolled in a Balance plan, they must each submit their own separate application, which will be subject to medical screening. If you need additional applications, you can print them out from our Web site, kp.org/care.
 
BALANCE PLAN ACKNOWLEDGEMENT FORM
   
For Balance Plan Applicants Only If you are applying for a Kaiser Permanente Balance Plan, please read and sign the notice below. (If you are applying for any other type of plan, you may simply disregard this notice.) Acknowledgement of Limited Benefit Coverage In choosing one of Kaiser Permanente’s Balance Plans, I understand that these plans do not provide coverage for some state mandated benefits. The following is a comparison of benefits provided under Kaiser Permanente Personal Advantage HMO plans that are either not covered or are significantly different under the Balance plans. If you have any questions about comparison of benefits between Personal Advantage HMO plans and the Balance plans, please call us at 1-800-232-4404 before you
 
 
Benefit Personal Advantage HMO Plans Personal Advantage Balance Plans
Maximum Benefit While Covered Unlimited $3,000,000
Maternity Services (all services related to prenatal, postnatal, and delivery care) Covered No coverage
Infertility Diagnosis Covered No coverage
Vision Exams Covered No coverage
Dental Care accidental injury Covered No coverage
Dental Care Non-surgical dental treatment for TMJ, including dental splints Covered No coverage
   
  I have read and understand the comparison of benefits between the plans being offered to me, and I understand the benefit limitations and exclusions of the Kaiser Permanente Balance plans.
   
  By entering my name here, I the primary applicant am submitting a legal, binding, and valid signature:
  Signature: Date:
   
   
  3. MEDICAL INFORMATION
 
  • Answer the questions below with respect to yourself and each family member applying for coverage.
  • If you can answer Yes for any applicant, fill in the Yes bubble and explain further—for each person the Yes applies to—on the chart in Question 8.
 
Have you or any family member applying for coverage:  
  1. been hospitalized in the last 12 months, except for pregnancy?
     Yes No
     
  2. required medical attention 6 or more times in the last 12 months, except for pregnancy?
     Yes No
     
  3. within the last 3 years, been advised to have, but have not yet had, surgery, treatment, examination, evaluation, or test for any medical condition?
     Yes No
     
  4. in the last 5 years, taken or used illegal drugs or prescription drugs not prescribed by a doctor?
     Yes No
     
  5. in the last 5 years, participated in or been advised to participate in a program that deals with your alcohol or substance abuse?
     Yes No
     
  6. ever been treated for, or had a doctor or other health care provider advise you that you have, any of the following conditions? Please mark all that apply.

     AIDS, ARC, HIV
     Sexually transmitted disease
     Hepatitis
     Hernia not repaired
     Back/neck pain or injury
     Bone marrow transplant
     Crohn’s or ulcerative colitis
     Depression or anxiety
     Mental health condition
     Eating disorder, anorexia nervosa/bulimia
     Heart or valve condition
     Asthma
     Emphysema/COPD
     Lung condition, other chronic condition
     High blood pressure
     High cholesterol
     Kidney/bladder condition — including kidney stones
     Liver condition or pancreas disorder
     Gallstones
     Anemia or other blood disorder
     
  1. (cont)
     Painful or irregular menstrual cycle or female reproductive disorders
     Lupus/SLE/inflammatory condition
     Breast implants
     Melanoma/breast/prostate/bladder cancer
     Skin cancer
     Other cancers
     Aneurysm
     MS/ALS/Parkinson’s/Alzheimer’s
     Neurologic condition
     Pacemaker or other implanted medical device
     Prostate condition
     Rheumatoid arthritis
     Seizures/headaches requiring medical treatment
     Sickle cell anemia
     Diabetes
     Stomach or intestinal problems or GI reflux
     Stroke
     Lumps, masses, tumors, or growths
     Ulcer
     Other conditions not specifically listed on application, even if not currently under treatment
     None of the above
     
  2. experienced unexplained and/or undiagnosed symptoms such as the following? Please mark all that apply.
     
    Fever
     Swollen glands
    Chest pain
     Shortness of breath
     Abdominal or pelvic pain
     Loss of consciousness
     Unexplained weight loss    		 Rectal bleeding
    Loss of appetite
     Dizziness
     Chronic fatigue
     Rash/skin problems
     Skin lesions
     Lumps
    Other
    None of the above


     

 

 
   
 
  1. If you indicated a Yes answer for any of the items in questions 1-7, please explain  and provide the following information below.

    Question Number, Person Treated, Explanation/Name of Illness or Disorder, Type of Treatment / Degree of Recovery, Treatment Dates (from and to), Name and Address of Attending Physician
   
   
 
  1. (a) Are you or any family member applying for coverage regularly taking any prescription medications?
     Yes No

    (b) If Yes, Please explain below with the following Information:
    Person Treated, Name of Medication, Dosage / Frequency, Treatment Dates (from and to), Name and Address of Attending Physician
 
   
   
  Answer the questions below for yourself and each family member applying for coverage. (D1, D2, and D3 etc should correspond to the Dependents you listed under Additional Applicants in the Personal Information section.) Choose the one most appropriate answer for each person applying and check that box. Write in numeric answers when asked.
   
  10. (a) If you have ever smoked cigarettes, what is or was your average daily usage?
 
 
  Self Spouse D1 D2 D3 D4 D5 D6 D7 D8
1/2 pack or less
1 pack
1 1/2 packs
2 or more packs
N/A
 
  10. (b) For how long?
 
 
  Self Spouse D1 D2 D3 D4 D5 D6 D7 D8
9 years or less
10 - 14 years
15 - 19 years
20 - 29 years
Over 30 years
N/A
   
  10. (c) Have you quit?
 
  Self Spouse D1 D2 D3 D4 D5 D6 D7 D8
Yes
No
If so, when?
   
  11. (a) Have you consumed more than 10 alcoholic beverages per week within the last 6 months?
 
  Self Spouse D1 D2 D3 D4 D5 D6 D7 D8
Yes
No
   
  11. (b) If yes for 11(a), write in the number of drinks consumed weekly
 
  Self Spouse D1 D2 D3 D4 D5 D6 D7 D8
Beer
Wine
Hard Liquor
   
  12. Are you an expectant parent or do you have a pending adoption?
 
  Self Spouse D1 D2 D3 D4 D5 D6 D7 D8
Yes
No
   
  13. Are you currently taking birth control medication, estrogen, Premarin, Depo-Provera, etc.?
 
  Self Spouse D1 D2 D3 D4 D5 D6 D7 D8
Yes
No
   
  14. For Females over age 11 only:
  (a) Are you pre-menstrual (have never menstruated), post-menopausal, or have you had a hysterectomy or tubal ligation?
 
  Self Spouse D1 D2 D3 D4 D5 D6 D7 D8
Yes
No
   
    (b) If No, date your most recent normal menstrual period
 
  Self Spouse D1 D2 D3 D4 D5 D6 D7 D8
Hard Liquor
   
   
  4. Application Agreement
   
  I hereby apply for enrollment for myself and eligible family dependents listed on this form, and I agree that the information listed is correct. Upon acceptance to the Health Plan, my en­closed check for the first month’s premium will be deposited or my credit card charged, and my coverage will begin on the first day of the month as assigned by Health Plan.


I authorize any physician or other health care professional, hospital or other health care facility, counselor, therapist, or any other medical or medically related facility or professional who has provided any services to me or any of my dependents applying for or having membership in any Kaiser Foundation Health Plan product (each, an “Applicant”) to give Kaiser Foundation Health Plan of Georgia, Inc., or its affiliates (“Kaiser Permanente”), their respective agents, employees, designees, or representatives, including my Kaiser Permanente agent or broker, any and all information or records relating to medical history, medical examinations, services rendered, or treatment given, including treatment for alcohol abuse, substance abuse, mental or emotional disorders, sexually transmitted diseases, HIV (Human Immunodeficiency Virus) status, AIDS (Acquired Immune Deficiency Syndrome), or ARC (AIDS-Related Complex) (“Medical Information”) of the Applicant. However, Medical Information does not include genetic information or “Psychotherapy Notes” (as defined by 45 C.F.R. ß 164.501). I understand that such Medical Information may be requested and used in connection with the review, investigation or evalu­ation of enrollment or of any claim for benefits after enrollment.

I also authorize Kaiser Permanente to disclose any and all such Medical Information related to any Applicant to any health care provider, health care service plan, self-insurer or insurance company for the purpose of review, investigation or evaluation of enrollment or of any claim for benefits after enrollment. I will sign new authorizations, if necessary, so that, in connection with the review, investigation or evaluation of enrollment or of any claim for benefits, Kaiser Permanente may request, use and disclose Medical Information and “Psychotherapy Notes.” Medical Information, once disclosed, may no longer be pro­tected by Federal privacy law, and may be further disclosed.

This authorization is effective immediately and will remain in effect for a period of thirty (30) months, except that it will remain in effect for use by Kaiser Permanente in connection with the review, investigation or evaluation of any claim for benefits for an Applicant if that Applicant is still a member of any Kaiser Foundation Health Plan. A photocopy of this authorization is as valid as the original, and I and my Kaiser Permanente agent or broker are entitled to receive a copy of this form. I may revoke this authorization (to the extent applicable to my Medical Information) at any time prior to its expiration. However, revocation is not effective to the extent that Kaiser Permanente has already taken action in reliance on it, or for so long as Kaiser Permanente may contest my enrollment or of any claim for benefits. I under­stand that the instructions for revoking authorizations are in Kaiser Permanente’s Notice of Privacy Practices.

NOTICES:
1. Any intentional material misstatement or omission of informa­tion may void your coverage and/or the coverage of your family members. (If you are unsure of your medical condition, please ask your current or previous physician to clarify your specific condition.)
2. YOU MUST IMMEDIATELY INFORM US if your health status or current medication changes at any time before your membership in Personal Advantage becomes effective. Failure to inform us of such changes can void your membership. You can choose to update your application information by telephone (404) 364-7001 (option 2), by fax (404) 365-4146, or by writing us at Kaiser Permanente Personal Advantage; 3495 Piedmont Road, NE; Building 9; Atlanta, GA 30305. All written and fax correspondence must be signed and dated.
3. After the effective date of this coverage, Health Plan may rescind your coverage and your dependent’s coverage retro­actively to the effective date (1) based on updated information, (2) upon learning that you failed to provide updated information, OR (3) upon learning that you intentionally provided any incorrect or incomplete answers on this application or in communications regarding it. If your coverage is rescinded, you will be billed for all services you received.
4. Georgia residents who do not qualify for Personal Advantage and are not current Kaiser Foundation Health Plan members may be eligible to participate in the State of Georgia Health Insurance Assignment System, a state-sponsored guaranteed-issue health care coverage program in which Kaiser Permanente participates. For more information, call 1-800-656-2298. Georgia residents who do not qualify for Personal Advantage and who are current Kaiser Foundation Health Plan members can choose to be considered for our conversion products, one of which is available to HIPAA-qualified individuals. If you wish to exercise that option, please contact our Customer Service Department at (404) 261-2590 to obtain an application.

IMPORTANT: Please read the conditions above, and sign and date below. All applications MUST be signed and dated by Primary Applicant, Spouse (if applicable), and any Dependent 18 years of age or older (if applicable). I have read and understand all of the above conditions and terms.
   
  I authorize the disclosure of premium billing, claim payment, and commission information to my broker of record and my spouse (if applicable) to expedite the servicing of my account.  Yes No
   
 
   
Signature of Primary Applicant

Date

   Signature of parent or guardian if Primary Applicant is under 18

Date
   
 
   
Signature of Spouse

Date

   Signature of parent or guardian if Primary Applicant is under 18

Date
   
   
  5. Payment Options
   
 
Automatic Draft Plan* Your most convenient and reliable option is this payment method. Payments are automatically deducted from your checking or savings account between the first and the fifth day of each month. To enroll, simply read and fill out the section below. BE SURE TO INCLUDE A VOIDED CHECK AND YOUR FIRST MONTH’S PREMIUM.
   
  *Note: If you choose the Automatic Draft Plan as your payment option, you are still required to send a check for your first month's premium and a voided check.  The automatic draft plan takes effect in your second month of coverage.
   
  I hereby authorize Kaiser Foundation Health Plan of Georgia, Inc., (Health Plan) to debit my checking or savings account with the financial institution named below. If a debit will differ from that of the previous month’s debit, Health Plan will notify me in writing at least seven days in advance of the change.

This authority is to remain in full force and effect until Health Plan has received written notification from me of its termination in such time and in such manner as to afford Health Plan reasonable opportunity to act on it. (Must give Health Plan 30 days.)

If an entry is erroneously initiated by Health Plan to my account, I have the right to have the amount of the entry credited to my account. However, I must give the financial institution a written notice within 15 days explaining that the entry was in error.
   
  Bank Name:   Member (Depositor) Account Number:
  Bank Address:
  Type of account: Savings Account Checking Account (attach a voided check) Other
   
  Member Name(s):
  Signed (member signature):
   
  Date: Signed (Depositor Signature):
  Date: Signed (2nd Depositor Signature if Joint Account):
   
   
Payment by Credit Card Your credit card will be charged for your/your family's first month's premium. Also, each month's premium will be automatically charged to your credit card on the 20th of the month prior unless you arrange another form of payment by calling (404) 364-7179. Your credit card will be charged only if you are accepted for membership.
   
  Type of Card:   Card Number:
  Expiration Date:   Name as it appears on card:
  Signature:
   
   
Monthly Service* You will receive a monthly invoice from Kaiser Permanente. Payment is due on or before the first day of each month. If payment is not received by this date, you are subject to termination of membership.
   
  *Note: If you choose the Payment by Monthly Invoice option, you are still required to send your first month's premium.
   
  If you do not choose a payment method, you will automatically receive a monthly invoice. You are still required to send your first month’s premium.