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Small business forms

  1. Help avoid processing delays — make sure you submit fully completed, current versions of the forms below. Use our form validation matrix to make sure you have the latest versions.

Use our New Small Group Eligibility Guide (PDF) to:

  • Verify that your clients qualify for small group coverage
  • Find out what documents you’ll need to submit

Use our New Group Enrollment Checklist (PDF) to:

  • Collect key documents to enroll a new group
  • Learn additional enrollment tips


New Group Enrollment Kit

Use the New Group Enrollment Kit along with the New Group Enrollment Checklist to ensure a smooth enrollment process.

Employee Enrollment or Declination
Each employee should complete either an Employee Enrollment or Declination of Coverage form if the employer is not using the Employer Attestation Declination of Coverage form.

5/1/20
  • Contact Change Request (PDF) — Your clients can use this form to change their billing contact, interested party contact, or contract signer information. (Updated 3/16/21)
  • Customer Address or Name Change Request (PDF) — Your clients can use this form to change their company address, name, or federal tax ID (EIN) number. (Updated 3/16/21)
  • Employee/Dependent Change (PDF) — Your clients’ employees can use this form to add or remove dependents from their accounts, change addresses, or change names. (English — updated 9/27/19)
  • Employee/Dependent Change (PDF) (Spanish — updated 10/8/19)
  • Employee/Dependent Change (PDF) (Chinese — updated 10/8/19)
  • Employee/Dependent Change (PDF) (Vietnamese – updated 11/2/20)
  • Employee Enrollment (PDF) — Your clients’ employees can use this form to enroll with Kaiser Permanente. (English — updated 5/1/20)
  • Employee Enrollment (PDF) (Spanish — updated 5/20/20)
  • Employee Enrollment (PDF) (Chinese — updated 5/20/20)
  • Employee Enrollment (PDF) (Vietnamese – updated 11/2/20)
  • Employer Attestation for COBRA/CAL-COBRA & TEFRA Status (PDF) — Use this form to let us know if you have a COBRA status change from Cal-COBRA to Federal COBRA or Federal COBRA to Cal-COBRA. Write in the effective date of change on the form. (Updated 1/27/21)
  • Federal COBRA application (PDF) — For groups with 20+ eligible employees, use the Federal COBRA application to cover your client’s former employees and their dependents. For groups with 2–19 eligible employees, your client’s former employees must contact the Kaiser Permanente Member Service Contact Center at 1-800-464-4000 for enrollment assistance.
  • Group Termination Request form — To receive this form, please contact your assigned Account Manager. If you don’t have an assigned Account Manager, contact the Small Business Customer Connection Team. For more information, please see our small business service tip on “Terminating a small group contract”.
  • HIPAA Authorization (PDF) — Your clients can use this form to authorize use and/or disclosure of patient health information. (English — updated 8/5/16)
  • New Group Application — 2019 (PDF) — Use this 2019 version of the New Group Application to help groups with 2019 effective dates add a PPO plan. (Updated 10/2/18)
  • Primary Administrator Online Access Request (PDF) — Your clients can use this form to request access to our secure online account services and set up automatic payments for the second month onward. (Updated 9/27/19)
  • Participation and contribution attestation (PDF) — Your client must complete this form to attest that their company continues to meet the minimum participation and contribution requirements for small business coverage. (Updated 9/27/19)
  • Payroll attestation (PDF) — Your clients can use this form if they're a new business (start-up, breakaway or establishing payroll from an existing business) and don't have payroll to document eligible employees.
  • Plan Add/Change Request — 2021 (PDF) — Groups that have already renewed and wish to add or discontinue plans should use this form to request a midyear plan change prior to their next renewal. (Updated 10/1/20) Fax changes to 800-369-8010 or email them to amt@kp.org. For changes to take place that month, we must receive them by 5 p.m. on the 15th of the month. Otherwise the changes will take place the following month.
  • Plan Add/Change Request — 2020 (PDF) — Groups that have already renewed and wish to add or discontinue plans should use this form to request a midyear plan change prior to their next renewal. (Updated 9/27/19) Fax changes to 800-369-8010 or email them to amt@kp.org. For changes to take place that month, we must receive them by 5 p.m. on the 15th of the month. Otherwise the changes will take place the following month.
  • Plan Add/Change Request — 2019 (PDF) — Groups that have already renewed and wish to add or discontinue plans should use this form to request a midyear plan change prior to their next renewal. (Updated 10/2/18) Fax changes to 800-369-8010 or email them to amt@kp.org. For changes to take place that month, we must receive them by 5 p.m. on the 15th of the month. Otherwise the changes will take place the following month. 
  • Subscriber Termination and Transfer (PDF) — Your clients can use this form to terminate an employee’s coverage or transfer an employee to a different enrollment unit. (Updated 3/16/21)

Small Business Change of Ownership

If you’re looking for a Small Business Change of Ownership form, please call our Small Business Services Customer Connection Team at 800-790-4661, option 3.

 
 
 
 
 
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