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Prior to Applying
 

Paper or plastic? How you choose to pay your first month’s premium may determine whether you apply by paper or continue online. If you would like to pay by check or money order, you will need to submit a paper application. If you would like to use credit/debit cards or electronic transfer from savings/checking, you can apply by paper or online. Whichever way you choose, please start by entering your ZIP code below.

You may be eligible for financial help from the federal government to lower your monthly premium. See if you qualify

If you are a current member with Individual and Family Plans and would like to look at other product options, please contact Member Services at 1-866-410-7536. Please do not use this site to request plan changes.

Paper or plastic? How you choose to pay your first month’s premium may decide whether you apply by paper or continue online. If you would like to pay by check or money order, you will need to submit a paper application. Only credit/debit cards or electronic transfer from savings/checking are accepted online. Whichever way you choose, please start by entering your ZIP code below.

You may be eligible for financial help from the federal government to lower your monthly premium. See if you qualify

Choose your path

How you choose to pay your first month’s premium may decide whether you apply by paper or continue online. If you would like to pay by check or money order, you will need to submit a paper application. Only credit/debit cards or electronic transfer from savings/checking are accepted online. Whichever way you choose, please start by entering your ZIP code below.

You may be eligible for financial help from the federal government to lower your monthly premium. See if you qualify

Due to site upgrades, only the paper application is available at this time. Please return this fall, when we'll launch new and enhanced apply online features.
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If you are applying for coverage with a 2012 effective date, please continue with the application process.

If you would like to apply for coverage with a 2013 effective date, please return to our website after November 16, 2012, when our 2013 plans and rates will be available.
If you are applying for coverage with a 2012 effective date, please continue with the application process.

If you would like to apply for coverage with a 2013 effective date, please return to our website after October 30, 2012, when our 2013 plans and rates will be available.
If you are applying for coverage with a 2012 effective date, please continue with the application process.

If you would like to apply for coverage with a 2013 effective date, please return to our website on or after November 1, 2012, when our 2013 plans and rates will be available.
If you are applying for coverage with a 2012 effective date, please continue with the application process.

If you would like to apply for coverage with a 2013 effective date, please return to our website on or after December 8, 2012, when our 2013 plans and rates will be available.
If you are applying for coverage with a 2012 effective date, please continue with the application process.

If you would like to apply for coverage with a 2013 effective date, please return to our website on or after October 31, 2012, when our 2013 plans and rates will be available.
The benefits and monthly rates listed are valid through December 31, 2012. If you would like to apply for these plans with a 2012 effective date, we must receive your application by December 8, 2012. Beginning January 1, 2013, the plans, benefits, and monthly rates for Kaiser Permanente for Individuals and Families plans will change.

If you would like to apply for coverage with a 2013 effective date, please return to our website on or after December 8, 2012, when our 2013 plans and rates will be available.
If you are applying for coverage with a 2012 effective date, please continue with the application process to lock in your 2012 rate.

If you would like to apply for coverage with a 2013 effective date, please come back on or after December 20, 2012, when our 2013 plans and rates should be available.

Important notice for existing Kaiser Permanente Individual and Family Plan members. If you're trying to change your plan, please call us so that we can assist you with the appropriate next steps.

 
Please use the navigation buttons provided. DO NOT use
your browser's "Back" or "Forward" buttons.
 
 
 
Thank you for your interest in Kaiser Permanente. To sign up for coverage in your area, please visit kp.org/wa/shop
Thank you for considering Kaiser Permanente. We currently do not offer health care coverage in your area. To find the coverage you need, please visit your state’s Health Insurance Marketplace.

Thank you for considering Kaiser Permanente. Kaiser Permanente will be offering our plans only through DC Health Link dchealthlink.com. As a Washington, D.C. resident, you must purchase your health plan through the DC Marketplace.

For more information on our plans or how to apply through DC Health Link, call us at 1-800-488-3590 TTY: 711. We’ll be happy to guide you through the process.

The ZIP code you entered is not within a Kaiser Permanente Individual and Family Plans service area.
You selected "Yes". Those of you who are entitled to Medicare Part A or enrolled in Medicare Part B can’t enroll in an individual and family plan. Please visit kp.org/medicare to learn more about your Medicare plan options or apply for coverage.
 
Please enter the ZIP code for your primary residence
* ZIP Code :
State:
    County:
   
Check Your Eligibility
* Are you or any dependent you’re applying for either entitled to Medicare Part A or enrolled in Medicare Part B?
If you selected "Yes," those of you who are entitled to Medicare Part A or enrolled in Medicare Part B can’t enroll in a KPIF plan. Please visit kp.org/medicare to learn more about your Medicare plan options or to apply for Medicare coverage. If you selected "Yes," those of you who are entitled to Medicare Part A or enrolled in Medicare Part B can’t enroll in an individual and family plan. Please visit kp.org/medicare to learn more about your Medicare plan options or to apply for Medicare coverage. If you selected "Yes," those of you who are entitled to Medicare Part A or enrolled in Medicare Part B can’t enroll in an individual and family plan. Please visit kp.org/medicare to learn more about your Medicare plan options or to apply for Medicare coverage.
You must complete the "Employer information" section below

You will not be issued an individual policy with the premiums, or a portion thereof, paid or reimbursed by an employer unless you submit a signed affidavit from the employer certifying that the employer has not had a small group health benefit plan providing coverage to any employee in the past twelve (12) months. To see if this applies to you, please answer the following questions. If left blank, your enrollment form will not be processed until you provide the responses to the questions.

* 1. Will an employer of 100 or fewer eligible employees be paying for or reimbursing an employee through wage adjustment or a health reimbursement arrangement for any portion of the premium on the policy being applied for?

If you answered Yes, please continue to question 2. If you answered No, please continue.

* 2. Did the employer have a small group health benefit plan providing coverage to any employee in the twelve (12) months prior to the date of this request for enrollment?

If the answer to both questions 1 and 2 is Yes, you (the applicant) will not be issued an individual policy with the premiums, or portion thereof, paid or reimbursed by the employer. If the answer to question 1 is Yes and the answer to question 2 is No, you (the applicant) must submit a signed affidavit from your employer certifying that the employer has not had a small group health benefit plan providing coverage to any employee in the previous twelve (12) months. The Employer affidavit form to be completed by the employer is at the back of this enrollment form. The submission of this affidavit does not guarantee that the individual policy you are applying for will be issued by the carrier. If you answer Yes to both questions 1 and 2, you may apply for individual coverage if you pay the full premium yourself and are not reimbursed in any way by your employer.

Affidavit Form (PDF)
Tell Us When You’re Applying
Select 1 option:
Select 1 option:
Select 1 Option:
Select 1 option:
†If you’ll be getting federal financial assistance, don’t use this application. We can help you apply through Connect for Health Colorado.

For help, contact us at 1-800-494-5314 or contact your broker.
For more information on qualifying life events, please visit kp.org/specialenrollment or call 1-800-494-5314.
For more information on qualifying life events, please visit kp.org/specialenrollment or call 1-800-494-5314.
For more information on qualifying life events, please visit kp.org/specialenrollment or call 1-800-494-5314.
For more information on qualifying life events, please visit kp.org/specialenrollment or call 1-800-494-5314.
For more information on qualifying life events, please visit kp.org/specialenrollment or call 1-800-494-5314.
For more information on qualifying life events, please visit kp.org/specialenrollment or call 1-800-494-5314.
For more information on qualifying life events, please visit kp.org/specialenrollment or call 1-800-494-5314.
For more information on qualifying life events, please visit kp.org/specialenrollment or call 1-800-494-5314.
Select the triggering event (or qualifying life event)
* If you selected “A special enrollment period,” choose the qualifying life event (proof of eligibility is required):
* If you selected “A special enrollment period,” choose the qualifying life event (proof of eligibility is required):
For more information on qualifying life events, please visit kp.org/specialenrollment or call 1-800-494-5314.
Select the triggering event (or qualifying life event)
* If you selected “A special enrollment period,” choose the qualifying life event (proof of eligibility is required):


*If your qualifying life event is loss of Kaiser Permanente coverage, we may review your prior membership records to establish eligibility.
†If you’ll be getting federal financial assistance, don’t use this form. We can help your apply at healthcare.gov
*If your qualifying life event is loss of Kaiser Permanente coverage, we may review your prior membership records to establish eligibility.
†If you’ll be getting federal financial assistance, don’t use this form. We can help your apply at marylandhealthconnection.gov
*If your qualifying life event is “Loss of health care coverage,” the date of the qualifying life event is the last day of full coverage under your prior plan. If your qualifying life event is loss of Kaiser Permanente coverage, we may review your prior membership records to establish eligibility.
If you are applying during a special enrollment period, please enter the date of your qualifying life event.
* If your qualifying life event is loss of Kaiser Permanente coverage, we may review your prior membership records to verify loss of minimum essential coverage.
† If you’ll be getting federal financial assistance, don’t use this form. We can help you apply at CoveredCA.com.
* If your qualifying life event is loss of KFHPNW coverage, we may review your prior membership records to establish eligibility.
† If you’ll be getting federal financial assistance, don’t use this form. We can help you apply at wahealthplanfinder.org.
* If your qualifying life event is loss of KFHPNW coverage, we may review your prior membership records to establish eligibility.
† If you’ll be getting federal financial assistance, don’t use this form. We can help you apply at healthcare.gov.
*If your qualifying life event is loss of Kaiser Permanente coverage, we may review your prior membership records to establish eligibility.
†If you’ll be getting federal financial assistance, don’t use this form. We can help you apply at healthcare.gov.
*If your qualifying life event is loss of Kaiser Permanente coverage, we may review your prior membership records to establish eligibility.
†If you’ll be getting federal financial assistance, do not use this form. We can help you apply at healthcare.gov.
Qualifying life event date
* Date of your qualifying life event
Effective Date:
* Is this application only for a child (or children)?:
applicationCheckList.CA.seperation.text
Note: Application must be accompanied by payment information for your initial premium. Please make certain that you have provided all information requested. Premiums for enrollments beginning on the 15th of the month will be prorated for that month only, after which the standard billing cycle (1st of the month) will apply.
  
Note: Effective dates for applicants under the age of 21 may vary.  
* Are ALL applicants current Kaiser Permanente members?
The 2011 Kaiser Permanente for Individuals and Families rates, benefits, and membership application form are still pending state regulatory review and may be subject to change. However, your application will be processed, and we will notify you of its status.


Do you qualify for a special enrollment period?

In general, you can only change or apply for health care coverage during the yearly open enrollment period. But if you have a qualifying life event, you may be able to change or apply for coverage for a limited time before or after this event occurs. This is called a special enrollment period.

To qualify for a special enrollment period, you must:
  • Have a qualifying life event
  • Have proof of your life event
  • Apply within 60 days of your life event. For some qualifying life events, you can enroll before the date of your event.
Examples of these types of qualifying life events include:
  • Getting married
  • Having a baby
  • Losing coverage because you lost your job
The special enrollment period generally lasts 60 days from the date of your qualifying life event.
For example, if you have a baby on June 1, you have 60 days — or by July 30 — to apply for coverage.

What if my life event happens during open enrollment?

Even if your qualifying life event happens during open enrollment, you’ll still have a special enrollment period.

What if I know about my life event in advance?

If your qualifying life event is a loss of coverage that you know about in advance, you may be able to apply for new coverage ahead of time. In this case, you have 60 days before and 60 days after the event to apply.

For more information on qualifying life events and start dates, visit kp.org/specialenrollment.

We will confirm the start date in your acceptance letter. If there is a delay in processing in your application, we'll select the next available start date.
How will the application be completed?
Select the method in which the application will be completed.
You may choose to complete the application online or on paper. If you choose to complete the application electronically (online), you also agree to receive a response from Kaiser Permanente electronically. You will have an opportunity to print a copy of your completed application and Kaiser Permanente's responses for your records.
 
Online Application
  (Using this preferred method helps ensure that your application is complete and may expedite processing)
  • You will complete the application online.

  • 4. If you do not wish to provide your email address, please follow instructions to download and mail a paper   application.

    If you think you might like to download the paper application, please do so now. Once you have started the online application, you will not be able to return to this page to download it.

    To download and complete a paper application click the link below.

 
Application Instructions
   
1. Sign the Application
    You'll need to sign the application with an e-signature letting us know that you understand the agreements and authorizations of the application. The signature of each Applicant who is an adult will be required to personally submit an electronic signature on his or her own behalf to sign the application.
   
   
2. Mailing Instructions
    To download and complete a paper application click the link below.
    Paper Application
    If you select to download and complete a paper application, please mail your application to:

Kaiser Permanente
California Service Center - KPIF
P.O. Box 23219
San Diego, CA 92193-9921
1. Provide Your Personal Information and Medical History
Depending on the type of plan you're applying for, you may need to have the following information on hand.
  • Medical History information for applicants, including medications and treating physician information
  • Medical History information for Applicants, including medications and treating physician information
The signature of each Applicant who is an adult will be required to personally submit an electronic signature on his or her own behalf to authorize release of medical information.
   
1. Sign the Application
    You'll need to sign the application with an e-signature letting us know that you understand the agreements and authorizations of the application. The signature of each Applicant who is an adult will be required to personally submit an electronic signature on his or her own behalf to sign the application.
    You'll need to sign the application with an e-signature letting us know that you understand the agreements and authorizations of the application. The signature of each Applicant who is an adult will be required to personally submit an electronic signature on his or her own behalf to sign the application.
   
   
2. Mailing Instructions
    To download and complete a paper application click the link below.
    Paper Application
    If you select to download and complete a paper application, please mail your application to:

Kaiser Permanente
California Service Center - KPIF
P.O. Box 23219
San Diego, CA 92193-9921
Application overview
1. Please provide all of the information that’s needed about you and your family.

2. Sign the online application with an e-signature. If you’re using the paper application, please sign in ink. A
   signature is needed for each person age 18 or over who will be covered.

3. Submit your application.
4. If you’re applying by mail or fax, download the paper application, fill it out, then mail or fax it to us. If you’re
   applying because of a triggering event (also called a qualifying life event), download the Proof of Triggering
   Event form and submit it with your application and supporting proof.
4. If you’re applying by mail or fax, download the paper application, fill it out, then mail or fax it to us. If you’re
   applying because of a qualifying life event, download the Proof of Qualifying Life Event Form and submit it with
   your application and supporting proof.
4. If you’re applying by mail or fax, download the paper application, fill it out, then mail or fax it to us. If you’re
   applying because of a triggering event (also called a qualifying life event), download the Proof of Triggering
   Event form and submit it with your application and supporting proof.
4. If you’re applying by mail or fax, download the paper application, fill it out, then mail or fax it to us. If you’re
   applying because of a qualifying life event, download the Proof of Qualifying Life Event Form and submit it with
   your application and supporting proof.
4. If you’re applying by mail or fax, download the paper application, fill it out, then mail or fax it to us. If you’re
   applying because of a triggering event (also called a qualifying life event), download the Proof of Triggering
   Event form and submit it with your application and supporting proof.

   Paper Application
   Special Enrollment Period
   Proof of Qualifying Life Event Form
4. If you’re applying by mail or fax, download the paper application, fill it out, then mail or fax it to us. If you’re
   applying because of a qualifying life event, download the Proof of Qualifying Life Event Form and submit it with
   your application and supporting proof.

   Paper Application
   Special Enrollment Period
   Proof of Qualifying Life Event Form
4. If you’re applying by mail or fax, download the paper application, fill it out, then mail or fax it to us. If you’re
   applying because of a qualifying life event, download the Proof of Qualifying Life Event Form and submit it with
   your application and supporting proof.
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60977708 Colorado January 2019
60590108 Colorado January 2018
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