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Small Business Group Administration Forms

Enrolling employees and dependents

Use these forms to enroll individual employees and their dependents (if applicable).

Fax completed forms to:

Northern CaliforniaSouthern California
Fax: 858-614-3344Fax: 858-614-3345

Changing employee/dependent information

Employees should use this form to add or remove dependents from their accounts or to change addresses or names.

Fax completed forms to:

Northern CaliforniaSouthern California
Fax: 858-614-3344Fax: 858-614-3345

Terminating employee coverage

Subscriber termination and transfer
Complete this form to terminate an employee's coverage or transfer an employee to a different enrollment unit.

Fax completed forms to:

Northern CaliforniaSouthern California
Fax: 858-614-3344Fax: 858-614-3345

Changing your coverage

Plan add/change request with 60 day attestation form
Use this form to request changes, such as adding a plan, deleting a plan, or changing your waiting period

Return completed forms to your Kaiser Permanente account representative.

Changing your group contact information

Contact change request
Use this form to change your billing contact, interested parties, or contract signer.

Fax completed forms to 1-800-369-8010.

Terminating your coverage

Group termination request form
Use this form to terminate your Kaiser Permanente coverage.

Fax completed form to your Kaiser Permanente account representative.


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