Kaiser Permanente Delta Dental - Benefits Enrollment Change Form

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    Kaiser Permanente & Delta Dental - Benefits Enrollment / Change Form
A. Employee Information
 1. Employee Personal Information
 Legal Last Name:                                 Legal First Name:                                Middle Initial:

 Social Security #:                               Date of Birth:                                   Gender:

 Street Address:

 City:                                            State:                               Zip Code:

 Work Phone:                                      Home Phone:                          Date of Hire:

 Work E-mail Address:


 2. Select your Classification:
    Active (#104306-0000)                                  Pre/Post Doc (Pre/Post Doc #104306-100)
    Early Retiree (Under Age 65) (#104306-0001)            Retiree (#104306-0001)
    Research Scholar (#104306-0000)


B. Reason for Request
 1. Select Reason:
     New Enrollee in Kaiser Permanente            Changes to Existing Kaiser Permanente Benefits

 2. Select your Status Change (check all that apply):
    Address Change / Move outside Service Area      End Domestic Partnership            New Domestic Partner
    Beneficiary Change                              Exhaustion of Funding (NRSA)        New Hire
    Birth / Adoption / Legal Guardianship           Leave of Absence                    Open Enrollment
    Death                                           Marriage                            Termination
    Divorce                                         Name Change

C. Kaiser Permanente HMO Plan Type
 1. Select Person(s) to be Covered under your Medical Coverage:
    Myself only (single coverage)              I am declining coverage for myself
    Myself and one dependent                   I am declining coverage for one dependent
    Myself and two or more dependents          I am declining coverage for all dependents

 2. Select Dental Carrier
     DeltaCare USA (#05301)                       Delta Dental PPO (#2545)

 3. Select Person(s) to be Covered under your Dental Coverage:
    Myself only (single coverage)              I am declining coverage for myself
    Myself and one dependent                   I am declining coverage for one dependent
    Myself and two or more dependents          I am declining coverage for all dependents
Reviewed by:            Effective Date:      COBRA Notice:            Medical Change       Dental Change
                                                                      Code:                Code:


Last Update: 10/07/09                         HRB02                                           Page 1 of 3
Employee Name: __________________________                   Social Security #:________________


D. Person(s) To Be Covered

  1. Employee
  Health Benefit Request Action:         Add   Delete   Dental Benefit Request Action:            Add         Delete
  Previous Kaiser Member?          Yes    No            DeltaCare USA Provider Name:
  Previous Kaiser Member Record #:                      DeltaCare USA Provider #:

  2. Spouse / Domestic Partner
  Health Benefit Request Action:         Add   Delete   Relationship:        Spouse       Domestic Partner
  Dental Benefit Request Action:         Add   Delete
  Name (Last, First, MI):                               Social Security #:

  Date of Birth:                                        Gender:         Male      Female
  Previous Kaiser Member?          Yes    No            Previous Kaiser Member Record #:
  DeltaCare USA Provider Name:                          DeltaCare USA Provider #:


  3. Child / Domestic Partner’s Child
  Health Benefit Request Action:         Add   Delete   Relationship:     Child       Domestic Partner’s Child
  Dental Benefit Request Action:         Add   Delete
  Name (Last, First, MI):                               Social Security #:

  Date of Birth:                                        Gender:         Male      Female
  Previous Kaiser Member?          Yes    No            Previous Kaiser Member Record #:
  DeltaCare USA Provider Name:                          DeltaCare USA Provider #:


  4. Child / Domestic Partner’s Child
  Health Benefit Request Action:         Add   Delete   Relationship:     Child       Domestic Partner’s Child
  Dental Benefit Request Action:         Add   Delete
  Name (Last, First, MI):                               Social Security #:

  Date of Birth:                                        Gender:         Male      Female
  Previous Kaiser Member?      Yes       No             Previous Kaiser Member Record #:
  DeltaCare USA Provider Name:                          DeltaCare USA Provider #:


  5. Child / Domestic Partner’s Child
  Health Benefit Request Action:         Add   Delete   Relationship:     Child       Domestic Partner’s Child
  Dental Benefit Request Action:         Add   Delete
  Name (Last, First, MI):                               Social Security #:

  Date of Birth:                                        Gender:         Male      Female
  Previous Kaiser Member?          Yes    No            Previous Kaiser Member Record #:
  DeltaCare USA Provider Name:                          DeltaCare USA Provider #:



Last updated: 10/07/09                            HRB02                                         Page 2 of 3
Employee Name: __________________________                        Social Security #:________________
E. Dual Medical or Dental Coverage
Name of Person(s) Covered:                                                Effective Date:
Name of Other Insurance Carrier(s):                                       Group Number(s):


F. Life Insurance & Long Term Disability Policy
1. Primary Beneficiary Name:                                      Date of Birth:
  Social Security Number:                                         Address:


  Relationship:                                                   (%):
2. Contingent Beneficiary Name:                                   Date of Birth:
  Social Security Number:                                         Address:


  Relationship:                                                   (%):


G. Election Authorization and Arbitration Agreement

Kaiser Foundation Health Plan Arbitration Agreement
I understand that (except for Small Claims Court cases, claims subject to a Medicare appeals procedure,
and, if I am enrolled in a group that is subject to ERISA, certain benefit-related disputes) any dispute
between myself, my heirs, relatives, or other associated parties on the one hand and Health Plan, its health
care providers, or other associated parties on the other hand, for alleged violation of any duty arising out of
or related to membership in Health Plan, including any claim for medical or hospital malpractice (a claim
that medical services were unnecessary or unauthorized or were improperly, negligently, or incompetently
rendered), for premises liability, or relating to the coverage for, or delivery of, services or items,
irrespective of legal theory, must be decided by binding arbitration under California law and not by lawsuit
or resort to court process, except as applicable law provides for judicial review of arbitration proceedings. I
agree to give up our right to a jury trial and accept the use of binding arbitration. I understand that the full
arbitration provision is contained in the Evidence of Coverage.

Kaiser Permanente HMO Plan Enrollee Signature (Required):                                            Date:

I authorize that any applicable pre-tax deductions be made from my paycheck for any employee premium
contribution that is required and that this election will continue during the term of my employment unless I change to
an ineligible status or revoke authorization through a written declination process in accordance with the terms of the
SDSU Research Foundation Plan Document(s). Due to the advantages of pre-tax contributions, I understand that
my election as a participant in any SDSU Research Foundation sponsored benefit program cannot be changed
during the plan year, other than open enrollment, unless I have a change in the status of my family. These are
defined under IRS regulations and SDSU Research Foundation Plan Document(s) as circumstances such as, but
not limited to: death, divorce, birth or adoption of a child, marriage, declaration or termination of a domestic
partnership, or change in spouse's or domestic partner's employment and must be reported to HR within 31 days of
the qualified family status change accompanied by the appropriate documentation.

I have read and understood the provisions set out on this form. All information on this form is correct and
true. I understand that it is the basis on which coverage may be issued under the plan. Any misstatements
or omissions may result in future claims being denied and/or my coverage being reduced.

Employee Signature:                                                                         Date:




Last updated: 10/07/09                                 HRB02                                        Page 3 of 3