LIST YOURSELF AND ALL ELIGIBLE DEPENDENTS
If you and your spouse are using different last names check applicable box:
Common Law Marriage
Wife Retaining Maiden Name
KAISER PERMANENTE - HMO (Option 1)
KAISER PERMANENTE HIGH DEDUCTIBLE (Option 2)
I understand that as part of my membership, the health plan service agreement requires that any claim for money damages asserted by a member or the member’s heirs or personal representatives must be submitted to binding arbitration instead of court trial.
PREVIOUS ENROLLMENT: If you or any other member of your family has previously been a member of the Kaiser Foundation Health Plan of Colorado, please let us know so that we may locate any previous medical records and have them available for the Physician involved in your future medical care.
Were you a previous member? YES NO
If yes, your identification number:
ATU SELF FUNDED PPO PLAN (Option 3)
ATU SELF FUNDED HIGH DEDUCTIBLE HEALTH PLAN (Option 4)
I certify that the information provided in this Application is true and complete to the best of my knowledge. I understand that any misrepresentation of information may void benefits retroactively to the date benefits began. I authorize use of all my (our) medical records for the Utilization Review, Quality Assurance and Peer Review programs conducted by the Plan or its agents.