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Small Business DECLINATION OF COVERAGE
IMPORTANT INFORMATION
Employees and owners: Please use this form only to decline group
health coverage.
Employers: Keep a copy of this form for your records. Ensure
name of carrier field is completed to avoid processing delays. If
you would like to terminate a subscriber or member, please use the
Subscriber Termination/Transfer Form.
1 COMPANY INFORMATION Company name Customer ID (if assigned)
2 REASON FOR DECLINING
I have been offered Kaiser Permanente group health coverage by
my employer. I voluntarily choose not to enroll myself in a Kaiser
Permanente plan at this time. I understand that the next
opportunity to enroll will be during the annual open enrollment
period or after a qualifying event.
Declination reason and carrier name impact the 70% participation
requirement. Only group coverage counts toward the participation
requirement.
Reason for declining (check 1):
I am covered by another employers health plan through my
spouse/domestic partner/parent.
Name of carrier:
I am covered by another plan offered by the employer listed
above or another employer I work for.
Name of carrier:
I am covered by an individual health plan.
Name of carrier:
I am covered by Medicare, Medi-Cal, or Tricare (military or VA
benefits).
Other reason for declining:
Note: Name of carrier feld must be completed.
3 SIGNATURE
If you decline coverage for yourself, youre also declining
coverage for your eligible dependent(s). You can only enroll or
change your coverage during an annual open enrollment period
established by your employer or during a special enrollment period
if you have experienced a qualifying event. You must request
coverage within 60 days of a qualifying event. Special enrollment
qualifying events include: Increase in your hours so that you meet
your employers requirement for medical plan eligibility Return from
a leave of absence Involuntary termination or loss of other group
coverage A dependent loses coverage elsewhere Marriage or addition
of a domestic partner Birth, adoption of a child, or placement for
adoption Court order Death of a spouse, domestic partner, or
dependent
Employee name (please print) Social Security number (last 4
digits)
Signature Date
X
Small Business 60645210 January 2018
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Language Assistance
Services
English: Language assistance
is available at no cost to you,
24 hours a day, 7 days a week.
You can request interpreter
services, materials translated
into your language, or in
alternative formats. Just call us
at 1-800-464-4000, 24 hours a
day, 7 days a week (closed
holidays). TTY users call 711.
Arabic :
.
4000-464-800-1 .
) (.
(.711 )
Armenian:
` 24 ,
7 :
,
:
` 1-800-464-4000 `
24 ` 7 ( ): TTY-
711:
Chinese: 7 24
7
24 1-800-757-7585
(TTY)
711
Farsi: 7 24
.
7 24.
4000-464-800-1) (
. 711 TTY .
Hindi: , 24 ,
,
,
1-800-464-4000 , 24
, ( )
TTY 711
Hmong: Muajkwc pab txhais lus pub dawb rau koj,
24 teev ib hnub twg, 7 hnub ib lim tiam twg..Koj thov
tau cov kev pab txhais lus, muab cov ntaub ntawv
txhais ua koj hom lus, los yog ua lwm hom.Tsuas hu
rau 1-800-464-4000, 24 teev ib hnub twg, 7 hnub ib
lim tiam twg (cov hnub caiv kaw). Cov neeg siv
TTY hu 711.
Japanese:
1-800-464-4000
TTY
711
Khmer: 24 7 1-800-464-4000 24 7 ( ) TTY 711
Korean:
.
,
.
1-800-464-4000
( ). TTY 711.
Navajo: Saad bee 1k1aayeed n1h0l= t11 jiik4,
naadiin doo bib22 d99 ah44iikeed tsostsid yisk32j9
damoo n1'1dleehj9. Atah halne4 1k1adoolwo[7g77 j0k7,
t1adoo le4 t11 h0hazaadj9 hadily22go, 47 doodaii
n11n1 l1 a[22 1daateh7g77 bee h1dadilyaago. Koj9
hodiilnih 1-800-464-4000, naadiin doo bib22 d99
ah44iikeed tsostsid yisk32j9 damoo n11dleehj9
(Dahodiyin biniiy4 eeaahgo 47 dadeelkaal). TTY
chodeeyool7n7g77 koj9 hodiilnih 711
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Punjabi: , 24 , 7 ,
,
,
1-800-464-4000 , 24 ,
7 ( ) TTY
711
Russian:
24 , 7 .
,
.
1-800-464-4000,
24 , 7
( ). TTY
711.
Spanish: Contamos con asistencia de idiomas sin costo
alguno para usted 24 horas al da, 7 das a la semana.
Puede solicitar los servicios de un intrprete, que los
materiales se traduzcan a su idioma o en formatos
alternativos. Solo llame al 1-800-788-0616, 24 horas al
da, 7 das a la semana (cerrado los das festivos). Los
usuarios de TTY, deben llamar al 711.
Tagalog: May magagamit na tulong sa wika nang wala
kang babayaran, 24 na oras bawat araw, 7 araw bawat
linggo. Maaari kang humingi ng mga serbisyo ng
tagasalin sa wika, mga babasahin na isinalin sa iyong
wika o sa mga alternatibong format. Tawagan lamang
kami sa 1-800-464-4000, 24 na oras bawat araw, 7 araw
bawat linggo (sarado sa mga pista opisyal). Ang mga
gumagamit ng TTY ay maaaring tumawag sa 711.
Thai: 24
1-800-464-4000 24
() TTY
711
Vietnamese: Dch v thng dch c cung cp min
ph cho qu v 24 gi mi ngy, 7 ngy trong tun. Qu
v c th yu cu dch v thng dch, ti liu phin dch
ra ngn ng ca qu v hoc ti liu bng nhiu hnh
thc khc. Qu v ch cn gi cho chng ti ti s
1-800-464-4000, 24 gi mi ngy, 7 ngy trong tun
(tr cc ngy l). Ngi dng TTY xin gi 711.
tel:1-800-788-0616
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Kaiser Permanente does not discriminate on the basis of age,
race, ethnicity, color, national origin, cultural background,
ancestry, religion, sex, gender identity, gender expression, sexual
orientation, marital status, physical or mental disability, source
of payment, genetic information, citizenship, primary language, or
immigration status.
Language assistance services are available from our Member
Services Contact Center 24 hours a day, seven days a week (except
closed holidays). Interpreter services, including sign language,
are available at no cost to you during all hours of operation. We
can also provide you, your family, and friends with any special
assistance needed to access our facilities and services. In
addition, you may request health plan materials translated in your
language, and may also request these materials in large text or in
other formats to accommodate your needs. For more information, call
1-800-464-4000 (TTY users call 711).
A grievance is any expression of dissatisfaction expressed by
you or your authorized representative through the grievance
process. A grievance includes a complaint or an appeal. For
example, if you believe that we have discriminated against you, you
can file a grievance. Please refer to your Evidence of Coverage or
Certificate of Insurance, or speak with a Member Services
representative for the dispute-resolution options that apply to
you. This is especially important if you are a Medicare, Medi-Cal,
MRMIP, Medi-Cal Access, FEHBP, or CalPERS member because you have
different dispute-resolution options available.
You may submit a grievance in the following ways:
By completing a Complaint or Benefit Claim/Request form at a
Member Services office located at a Plan
Facility (please refer to Your Guidebook for addresses)
By mailing your written grievance to a Member Services office at
a Plan Facility (please refer to Your
Guidebook for addresses)
By calling our Member Service Contact Center toll free at
1-800-464-4000 (TTY users call 711)
By completing the grievance form on our website at kp.org
Please call our Member Service Contact Center if you need help
submitting a grievance.
The Kaiser Permanente Civil Rights Coordinator will be notified
of all grievances related to discrimination on the basis of race,
color, national origin, sex, age, or disability. You may also
contact the Kaiser Permanente Civil Rights Coordinator directly at
One Kaiser Plaza, 12th Floor, Suite 1223, Oakland, CA 94612.
You can also file a civil rights complaint with the U.S.
Department of Health and Human Services, Office for Civil Rights
electronically through the Office for Civil Rights Complaint
Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone
at: U.S. Department of Health and Human Services, 200 Independence
Avenue SW, Room 509F, HHH Building, Washington, D.C. 20201,
1-800-368-1019, 1-800-537-7697 (TDD). Complaint forms are available
at
http://www.hhs.gov/ocr/office/file/index.html.
https://ocrportal.hhs.gov/ocr/portal/lobby.jsfhttp://www.hhs.gov/ocr/office/file/index.html
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Kaiser Permanente no discrimina a ninguna persona por su edad,
raza, etnia, color, pas de origen, antecedentes culturales,
ascendencia, religin, sexo, identidad de gnero, expresin de gnero,
orientacin sexual, estado civil, discapacidad fsica o mental,
fuente de pago, informacin gentica, ciudadana, lengua materna o
estado migratorio.
La Central de Llamadas de Servicio a los Miembros (Member
Service Contact Center) brinda servicios de asistencia con el
idioma las 24 horas del da, los siete das de la semana (excepto los
das festivos). Se ofrecen servicios de interpretacin sin costo
alguno para usted durante el horario de atencin, incluido el
lenguaje de seas. Tambin podemos ofrecerle a usted, a sus
familiares y amigos cualquier ayuda especial que necesiten para
acceder a nuestros centros de atencin y servicios. Adems, puede
solicitar los materiales del plan de salud traducidos a su idioma,
y tambin los puede solicitar con letra grande o en otros formatos
que se adapten a sus necesidades. Para obtener ms informacin, llame
al 1-800-788-0616 (los usuarios de la lnea TTY deben llamar al
711).
Una queja es una expresin de inconformidad que manifiesta usted
o su representante autorizado a travs del proceso de quejas. Una
queja incluye una queja formal o una apelacin. Por ejemplo, si
usted cree que ha sufrido discriminacin de nuestra parte, puede
presentar una queja. Consulte su Evidencia de Cobertura (Evidence
of Coverage) o Certificado de Seguro (Certificate of Insurance), o
comunquese con un representante de Servicio a los Miembros (Member
Services) para conocer las opciones de resolucin de disputas que le
corresponden. Esto tiene especial importancia si es miembro de
Medicare, Medi-Cal, MRMIP (Major Risk Medical Insurance Program,
Programa de Seguro Mdico para Riesgos Mayores), Medi-Cal Access,
FEHBP (Federal Employees Health Benefits Program, Programa de
Beneficios Mdicos para los Empleados Federales) o CalPERS ya que
dispone de otras opciones para resolver disputas.
Puede presentar una queja de las siguientes maneras:
completando un formulario de queja o de reclamacin/solicitud de
beneficios en una oficina de Servicio a los
Miembros ubicada en un centro del plan (consulte las direcciones
en Su Gua)
enviando por correo su queja por escrito a una oficina de
Servicio a los Miembros en un centro del plan
(consulte las direcciones en Su Gua)
llamando a la lnea telefnica gratuita de la Central de Llamadas
de Servicio a los Miembros al1-800-788-0616 (los usuarios de la
lnea TTY deben llamar al 711)
completando el formulario de queja en nuestro sitio web en
kp.org
Llame a nuestra Central de Llamadas de Servicio a los Miembros
si necesita ayuda para presentar una queja.
Se le informar al coordinador de derechos civiles (Civil Rights
Coordinator) de Kaiser Permanente de todas las quejas relacionadas
con la discriminacin por motivos de raza, color, pas de origen,
gnero, edad o discapacidad. Tambin puede comunicarse directamente
con el coordinador de derechos civiles de Kaiser Permanente en One
Kaiser Plaza, 12th Floor, Suite 1223, Oakland, CA 94612.
Tambin puede presentar una queja formal de derechos civiles de
forma electrnica ante la Oficina de Derechos Civiles (Office for
Civil Rights) en el Departamento de Salud y Servicios Humanos de
los Estados Unidos (U. S. Department of Health and Human Services)
mediante el portal de quejas formales de la Oficina de Derechos
Civiles, en https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, o por
correo postal o por telfono a: U.S. Department of Health and Human
Services, 200 Independence Avenue SW, Room 509F, HHH Building,
Washington, D.C. 20201, 1-800-368-1019, 1-800-537-7697 (lnea TDD).
Los formularios de queja formal estn disponibles en
http://www.hhs.gov/ocr/office/file/index.html.
https://ocrportal.hhs.gov/ocr/portal/lobby.jsfhttp://www.hhs.gov/ocr/office/file/index.html
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Kaiser Permanente
24 1-800-757-7585TTY711
:MedicareMedi-CalMRMIPMedi-Cal AccessFEHBPCalPERS
/
1-800-757-7585TTY
711
kp.org
Kaiser PermanenteKaiser Permanente One Kaiser Plaza, 12th Floor,
Suite 1223, Oakland, CA 94612
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf U.S. Department
of Health and Human Services, 200 Independence Avenue
SW, Room 509F, HHH Building, Washington, D.C. 20201,
1-800-368-1019,
1-800-537-7697TDD)http://www.hhs.gov/ocr/office/file/index.html
https://ocrportal.hhs.gov/ocr/portal/lobby.jsfhttp://www.hhs.gov/ocr/office/file/index.html
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