Primary applicant
Page 1 of 12
1086774819 California 2024
Application for health coverage
Individual and Family Plans
Who can use
this
application?
You may use this application to apply for a Kaiser Permanente for Individuals and Families
(KPIF) plan.
• If you want coverage for your family on the same KPIF plan, please fill out one application for the family.
If someone in your family wants a different health plan, they must complete a separate application.
• To be eligible for KPIF coverage, you must live in our California service area.
Who should
not use this
application?
• If you or any dependent you’re applying for are entitled to Medicare Part A or are enrolled in
Medicare Part B, that applicant is not eligible to apply for new KPIF coverage. Please visit
kp.org/medicare to learn more about your Medicare plan options or to apply for Medicare coverage.
• Please note the Health Insurance Counseling and Advocacy Program (HICAP) provides health
insurance counseling to California residents free of charge. Call HICAP at 1-800-434-0222 to
learn more. See page 12 to find your local HICAP program information.
• If you qualify for and want federal or state financial assistance to help pay for copays, coinsurance,
deductibles, or premiums, don’t complete this application. You must apply for coverage through
Covered California at CoveredCA.com.
• To make changes to your existing KPIF account, call 1-800-464-4000.
Things to
remember
• If you’re applying during open enrollment, the date we receive your application may change your
effective date — it will usually be January 1 if you apply by December 31. Please send this application
back as quickly as you can — or you can apply faster online at buykp.org/apply.
• If you’re applying during a special enrollment period, go to kp.org/specialenrollment
or call 1-800-494-5314 for instructions.
• Please answer all questions, and type or print using ink only. Leave an empty box in between words,
and put a hyphen in the box for hyphenated names.
• Remember, enrolling in a new plan won’t automatically cancel any other coverage you have. To avoid
paying for 2 plans or having a gap in coverage, make sure to cancel any other coverage as of the day
before your new coverage starts.
• To make sure your application is processed in time and isn’t canceled, please return every page of
the application, completed, with all the required signatures, first month’s payment, and proof of your
qualifying life event (if required). Send these materials by mail to:
Kaiser Permanente for Individuals and Families
P.O. Box 23127
San Diego, CA 92193-9921
Or send it by secure fax to: 1-855-355-5334
Note: Checks must be mailed and can’t be faxed.
Need help?
• For help with completing this application, please call 1-800-494-5314 (TTY 711).
• We’ll provide language assistance at no cost to you.
• If you’re working with a broker, please call them for assistance.
All plans are offered and underwritten by Kaiser Foundation Health Plan, Inc., One Kaiser Plaza, Oakland, CA 94612.
Page 2 of 12
1086774819 California 2024
Primary applicant
STEP 1: Choose your enrollment period
Select one option:
Open enrollment (skip to Step 2)
A special enrollment period (continue below)
Choose your qualifying life event. If you had more than one, review your options because effective dates vary by event. Proof of eligibility is also
required within 10 calendar days. Visit kp.org/specialenrollment or call 1-800-494-5314 for more about qualifying life events.
Loss of minimum essential health coverage (write the last full day you
had coverage)*
Gaining or becoming a dependent through marriage or domestic partnership
Gaining or becoming a dependent through the birth of a child, adoption, or
placement for adoption or foster care
Note: In this case, you also need to choose between 2 effective date options:
The date of birth, adoption, or placement for adoption or foster care
The first day of the month after we receive the application
Losing a dependent through divorce, dissolution of domestic partnership,
or legal separation
Death of the subscriber or a dependent
Child support order or other court order to cover a dependent
Note: In this case, you also need to choose between 2 effective date options:
The date of the child support order or other court order to cover
a dependent
The first day of the month after the court order date
Permanent relocation with access to new plans
Determination by Covered California of exceptional
circumstances
Eligibility to purchase an individual health plan through
an individual coverage health reimbursement arrangement
(ICHRA) or a qualified small employer health reimbursement
arrangement (QSEHRA)
Domestic violence or spousal abandonment occurring within
the household
Discontinuation of employer contribution to COBRA premium
Release from incarceration
Misinformation about enrollment in minimum
essential coverage
Provider network changes
Contract violation
Eligibility for app-based transportation or delivery network
company health care stipend
Please write the date of your qualifying life event.
(mm/dd/yyyy)
*
If
your qualifying life event is loss of Kaiser Permanente coverage, we may review membership records to check when and why you lost coverage.
STEP 2: Choose your health plan
Choose one health plan. If any family members are applying for different health plans, please submit a separate application for each plan.
Bronze
Kaiser Permanente –
Bronze 60 HDHP HMO
Kaiser Permanente –
Bronze 60 HMO
Kaiser Permanente –
Bronze 60 HMO 8200/0%
Silver
Kaiser Permanente –
Silver 70 HMO Off Exchange
Kaiser Permanente –
Silver 70 HMO 2850/50
Kaiser Permanente –
Silver 70 HDHP HMO 3600/25%
Gold
Kaiser Permanente –
Gold 80 HMO Coinsurance
Kaiser Permanente –
Gold 80 HMO
Platinum
Kaiser Permanente –
Platinum 90 HMO
For applicants under 30 or with hardship exemptions
Minimum coverage plans are available to applicants who will be younger than 30 on the effective date, or who provide a certificate of exemption that
shows hardship or lack of affordable coverage. We won’t be able to process your application without the certificate of exemption if you are 30
and older. To see if you qualify, please go to CoveredCA.com/exemptions and follow the instructions.
Kaiser Permanente – Minimum Coverage HMO
For information about health and dental benefits and limitations, cost-sharing amounts, and premiums, please review the details in your enrollment
materials. To request a copy of the Combined Membership Agreement, Evidence of Coverage, and Disclosure Form for a particular plan, please go to
kp.org/plandocuments, call 1-800-464-4000, or contact your broker.
Page 3 of 12
1086774819 California 2024
Primary applicant
STEP 3: Choose your optional adult dental plan
Dental coverage is included in your health plan for child members until the end of the month in which the member turns 19. Kaiser Permanente
offers an optional dental insurance plan to adults, which includes those individuals whose eligibility for pediatric dental services has ended. This
optional coverage is available for an additional charge. Our optional adult dental coverage is underwritten by Kaiser Permanente Insurance Company
(KPIC), a subsidiary of Kaiser Foundation Health Plan, Inc. (KFHP), and administered by Delta Dental of California, one of the nation’s largest and most
experienced dental benefits providers. Please refer to the Summary of Dental Benefits and Coverage Disclosure Matrix (SDBC) for complete details of the
KPIC dental plan by visiting kp.org/kpic-dental.
Please choose one option below.
Yes. I am requesting enrollment in the KPIC dental insurance plan that is available to me as a supplemental option to my health plan coverage.
Kaiser Permanente Insurance Company, a subsidiary of Kaiser Foundation Health Plan, Inc., underwrites the KPIC dental insurance plan. Once
enrolled, I understand I can’t cancel my dental coverage without also canceling my health plan coverage, except during open enrollment or a
special enrollment period.
No. I’m not interested in optional dental coverage.
Page 4 of 12
1086774819 California 2024
Primary applicant
STEP 4: Enter your information
Primary applicant
In an individual plan, the primary applicant is the person who will be covered by the health plan. In a family plan,
the primary applicant is the family member on the health plan who is authorized to make changes to the account. If
this application is only for a child under 18, the child is the primary applicant.
First name
MI
Last name
Date of birth (mm/dd/yyyy)
Former medical record number (if any) State (if any)
—
Gender:
Male
Female
Undeclared
Social Security number (if any)
-
-
Home address (no P.O. boxes, please)
City
State ZIP code County
Phone (mobile phone if available)
-
-
Mailing address Check if same as home address.
City
State ZIP code
Preferred language spoken (if not English) Preferred language read (if not English)
Email address
Parent or legal guardian
Please complete this section if the primary applicant is a child under 18.
The parent or legal guardian must be 18 or older.
First name
MI
Last name
Date of birth (mm/dd/yyyy)
Gender:
Male
Female
Undeclared
Social Security number (if any)
-
-
Preferred language spoken (if not English) Preferred language read (if not English)
Page 5 of 12
1086774819 California 2024
Primary applicant
Spouse/domestic partner to be covered
A domestic partner is a person registered and legally recognized as your
domestic partner by the state of California.
—
-
-
—
-
-
First name
MI
Last name
Choose one:
Spouse
Domestic
partner
Date of birth (mm/dd/yyyy)
Former medical record number (if any) State (if any)
—
Gender:
Male
Female
Undeclared
Social Security number (if any)
Parent(s)/Stepparent(s) to be covered
-
-
If you have more than 2 parent(s)/stepparent(s) to be covered, please fill out an
extra copy of this page and submit it with your application.
1
First name MI
Last name
Date of birth (mm/dd/yyyy)
Former medical record number (if any) State (if any)
Gender:
Male
F
emale
Undeclar
ed
Social Security number (if any)
2
F
irst name MI
La
st name
Date of
birth (mm/dd/yyyy)
Former medica
l record number (if any) State (if any)
Gender:
Male
F
emale
Undeclar
ed
Social Security number (if any)
Page 6 of 12
1086774819 California 2024
Primary applicant
Dependents to be covered
If you have more than 3 dependents to be covered, please fill out an extra copy of this page
and submit it with your application.
1
First name
MI
Last name
Date of birth (mm/dd/yyyy)
Former medical record number (if any) State (if any)
—
Gender:
Male
Female
Undeclared
Social Security number (if any)
-
-
Relationship to primary applicant
2
First name
MI
Last name
Date of birth (mm/dd/yyyy)
Former medical record number (if any) State (if any)
—
Gender:
Male
Female
Undeclared
Social Security number (if any)
-
-
Relationship to primary applicant
3
First name
MI
Last name
Date of birth (mm/dd/yyyy)
Former medical record number (if any) State (if any)
—
Gender:
Male
Female
Undeclared
Social Security number (if any)
-
-
Relationship to primary applicant
Page 7 of 12
1086774819 California 2024
Primary applicant
STEP 5: Choose an authorized representative (if you have one)
You can give a trusted friend or relative permission to talk about this application with us, see your information, or act for you on matters related to this
application only. This person is called an authorized representative.
First name MI
Last name Phone (mobile phone if available)
By signing, you’ve appointed this person as your legally authorized representative to get official information about this application,
and to act for you on matters related to this application.
Pri
mary applicant (parent or legal guardian for children under 18)
Date (mm/dd/yyyy)
STEP 6: Sign the application agreement
Important: All applicants, parent(s)/stepparent(s), and dependents 18 and older must read, sign, and date below. If the primary applicant is a child
under 18, then their parent or legal guardian must sign. By signing, the parent or legal guardian agrees to be responsible for paying all premiums,
copays, coinsurance, and deductibles for all the applicants listed on this application. A copy of your agreement with your signature is as valid as the
original. If signatures are missing, we will cancel the application. If there are more than 2 parent(s)/stepparent(s) and/or dependents 18 and older
signing, please attach a copy of this page with the additional signatures. To be eligible for KPIF coverage, you and any dependent you’re applying for
can’t be entitled to Medicare Part A or enrolled in Medicare Part B.
•
I verify that no applicant listed on this form is entitled to Medicare Part A or enrolled in Medicare Part B.
•
I understand that Kaiser Foundation Health Plan, Inc., will rely on the information provided in this application. If any information is found to be fraudulent
or intentionally misrepresented, then Kaiser Foundation Health Plan, Inc., may choose to terminate coverage back to the coverage effective date.
•
If I worked with a broker, I permit Kaiser Permanente to share the enrollment and disenrollment information listed on this application with them. I
understand that the broker or Kaiser Permanente representative may get financial and/or nonfinancial payments from Kaiser Permanente because
they assisted me with this application.
•
By providing my email address and mobile phone number, I understand I may receive email and text communications from Kaiser Permanente.
X
Primary applicant (parent or legal guardian for children under 18)
Date (mm/dd/yyyy)
X
Spouse/domestic partner
Date (mm/dd/yyyy)
X
Parent/stepparent
Date (mm/dd/yyyy)
X
Parent/stepparent
Date (mm/dd/yyyy)
X
Dependent (18 and older)
Date (mm/dd/yyyy)
X
Dependent (18 and older)
Date (mm/dd/yyyy)
-
-
X
Page 8 of 12
1086774819 California 2024
Primary applicant
STEP 7: Sign the Kaiser Foundation Health Plan, Inc., arbitration agreement
I understand that (except for Small Claims Court cases, claims subject to a Medicare appeals procedure or the ERISA claims procedure regulation,
and any other claims that cannot be subject to binding arbitration under governing law) any dispute between myself, my heirs, relatives, or other
associated parties on the one hand and Kaiser Foundation Health Plan, Inc. (KFHP), any contracted health care providers, administrators, or other
associated parties on the other hand, for alleged violation of any duty arising out of or related to membership in KFHP, 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 Combined Membership Agreement, Evidence of Coverage, and Disclosure Form.
X
Prima
ry applicant (parent or legal guardian for children under 18)
X
Date (mm/dd/yyyy)
Spouse/domestic partner
X
Date (mm/dd/yyyy)
Parent/stepparent
Date (mm/dd/yyyy)
X
Parent/stepparent
X
Date (mm/dd/yyyy)
Dependent (18 and older)
X
Date (mm/dd/yyyy)
Dependent (18 and older)
Date (mm/dd/yyyy)
A copy of your agreement with your signature is as valid as the original. If signatures are missing, we will cancel the application. If there are more
than 2 parent(s)/stepparent(s) and/or dependents 18 and older signing, ple
ase attach a copy of this page with the additional signatures.
Page 9 of 12
1086774819 California 2024
Primary applicant
STEP 8
: Enter first month’s payment details
Payment information
First name of person responsible for payment
MI
Last name of person responsible for payment
Address
City
State ZIP code
Email address
Payment options
(choose one)
Electronic payment
Check
Money order
Credit card
Debit card
X
If electronic payment, select account type: Checking account Savings account
I authorize Kaiser Foundation Health Plan, Inc. (KFHP), and the designated financial institution to accept this transfer of the first month’s payment
amount from my checking or savings account.
Bank name
Routing number
Account number
Account holder’s first name
MI
Account holder’s last name
X
Account holder’s signature
Date (mm/dd/yyyy)
If check or money order
Write the name of the primary applicant on the check. Mail payment with your application to the address listed on page 1.
To pay with a credit or debit card, please fill out the section below.
Cardholder’s first name as it appears on card MI
Cardholder’s last name as it appe
ars on card
Card number Expiration date (mm/yyyy)
Ca
rdholder’s signature
Date (mm/dd/yyyy)
Page 10 of 12
1086774819 California 2024
Primary applicant
Automatic monthly payments (optional)
To cancel or update automatic payments, go to kp.org/payonline or call the Member Service Contact Center at 1-888-236-4490.
Do you want to sign up for automatic monthly payments?
Yes
I want to enter a new payment method here. (Please fill out this page.)
Please use the same payment method I provided for my first month’s
payment. (Skip this page.)
No, I don’t want automatic monthly payments. (Skip this page)
First name of person responsible for payment
MI
Last name of person responsible for payment
Billing address
City
State ZIP code
Email address
Automatic payment options
(choose one)
Electronic payment
Credit card (debit cards can’t be used)
X
If electronic payment, select account type: Checking account Savings account
I authorize Kaiser Foundation Health Plan, Inc. (KFHP), and the designated financial institution to accept this transfer from my checking or savings account.
Bank name
Routing number
Account number
Account holder’s first name
MI
Account holder’s last name
X
Account holder’s signature
Date (mm/dd/yyyy)
To pay with a credit card, please fill out the section below.
Cardholder’s first name as it appears on card MI
Cardholder’s last name as it appears on card
Car
d number Expiration date (mm/yyyy)
Card
holder’s signature
Date (mm/dd/yyyy)
Page 11 of 12
1086774819 California 2024
Primary applicant
For applicants using a broker or Kaiser Permanente representative
If a broker or Kaiser Permanente representative (employee) helped you decide which plan to enroll in or helped you fill out this application, please
make sure they complete this page.
The broker may receive monetary payments or other compensation from Kaiser Permanente in connection with your purchase of this coverage.
Our standard compensation range is $13–$19 per member per month plus a potential bonus. To learn more, visit kp.org/brokercompensation.
Note: Premiums are the same whether or not you use a broker or Kaiser Permanente representative.
To be completed by your broker or representative after you complete this application:
Notice to broker or Kaiser Permanente representative: If you have assisted the applicant in submitting the application, the law requires that you attest
to this assistance. If, in making this attestation, you state as true any material fact you know to be false, you will be subject to a civil penalty of up
to ten thousand dollars ($10,000), as authorized under California Health and Safety Code section 1389.8(c) or Insurance Code section 10119.3, in
addition to any other applicable penalties or remedies available under current law.
Agency name Agency ID number
Broker or Kaiser Permanente representative (first, middle, last)
Address
City
State ZIP code
Kaiser Permanente—appointed ID number National producer number (NPN)
Phone (mobile phone if available) Fax
-
-
-
-
Email address
You must answer the following question by selecting Yes or No:
I assisted the applicant in submitting this application. To the best of my knowledge, the information on this application is complete and accurate.
I explained to the applicant, in easy-to-understand language, the risk to the applicant of providing inaccurate information, and the applicant
understood the explanation.
Yes
No
X
Broker or Kaiser Permanente representative
Date (mm/dd/yyyy)
Page 12 of 12
1086774819 California 2024
Local HICAP Offices by California County
Alameda County
333 Hegenberger Road, Suite 850
Oakland, CA 94621
510-839-0393
Alpine, Amador, Calaveras, Mariposa,
and Tuolumne Counties
19074 Standard Road, Suite A
Sonora, CA 95370
209-532-6272 ext. 226
Butte, Colusa, Glenn, Plumas,
and Tehama Counties
25 Main Street, Room 202
Chico, CA 95929-0799
530-898-6716
Contra Costa County
400 Ellinwood Way
Pleasant Hill, CA 94523
Inside Contra Costa from
a landline phone:
1-800-510-2020
Out of state: 925-655-1393
Del Norte County
1765 Northcrest Drive
Crescent City, CA 95531
707-464-7876
El Dorado, Nevada, Placer,
Sacramento, San Joaquin, Sierra,
Sutter, Yolo, and Yuba Counties
505 12th Street
Sacramento, CA 95814
1-800-434-0222
916-376-8915
Fresno and Madera Counties
5363 N. Fresno Street
Fresno, CA 93710
559-224-9117
Humboldt County
333 J Street
Eureka, CA 95501
707-444-3000
Imperial and San Diego Counties
5151 Murphy Canyon Road, Suite 110
San Diego, CA 92123
Imperial: 760-353-0223
San Diego: 858-565-8772
Inyo, Mono, Riverside,
and San Bernardino Counties
Council on Aging Southern California
2280 Market Street, Suite 140
Riverside, CA 92501
909-256-8369
Kern County
5357 Truxtun Ave.
Bakersfield, CA 93301
661-868-1000
Kings and Tulare Counties
3350 W. Mineral King
Visalia, CA 93291
559-713-2875
1-800-434-0222
Lake, Marin, Mendocino, Napa,
Solano, and Sonoma Counties
1129 Industrial Ave., Suite 201
Petaluma, CA 94954
1-800-434-0222
707-526-4108
Lassen, Modoc, Shasta, Siskiyou,
and Trinity Counties
1647 Hartnell Ave., Suite 8
Redding, CA 96002
530-223-0999
Los Angeles County
520 S. Lafayette Park Place, Suite 214
Los Angeles, CA 90057
213-383-4519
Within L.A. County: 1-800-824-0780
Merced County
851 West 23rd Street
Merced, CA 95340
209-385-7550
Monterey County
247 Main Street
Salinas, CA 93901
831-655-1334
Orange County
2 Executive Circle, Suite 175
Irvine, CA 92614
714-560-0424
San Benito and Santa Cruz Counties
1777 A Capitola Road
Santa Cruz, CA 95062
831-462-5510
San Francisco County
601 Jackson Street, 2nd Floor
San Francisco, CA 94133
415-677-7520
San Luis Obispo
and Santa Barbara Counties
528 South Broadway
Santa Maria, CA 93454
805-928-5663
San Mateo County
1710 S. Amphlett Blvd., Suite 100
San Mateo, CA 94402
650-627-9350
Santa Clara County
3100 De La Cruz Blvd., Suite 310
San Jose, CA 95054
408-350-3200, option 2
Stanislaus County
3500 Coffee Road, Suite 19
Modesto, CA 95355
209-558-4540
Ventura County
646 County Square Drive, Suite 100
Ventura, CA 93003
805-477-7310
Nondiscrimination Notice
Discrimination is against the law. Kaiser Permanente follows State and Federal civil rights laws.
Kaiser Permanente does not unlawfully discriminate, exclude people, or treat them differently
because of age, race, ethnic group identification, color, national origin, cultural background,
ancestry, religion, sex, gender, gender identity, gender expression, sexual orientation, marital status,
physical or mental disability, medical condition, source of payment, genetic information,
citizenship, primary language, or immigration status.
Kaiser Permanente provides the following services:
• No-cost aids and services to people with disabilities to help them communicate better with
us, such as:
Qualified sign language interpreters
Written information in other formats (braille, large print, audio, accessible electronic
formats, and other formats)
• No-cost language services to people whose primary language is not English, such as:
Qualified interpreters
Information written in other languages
If you need these services, call our Member Service Contact Center at 1-800-464-4000 (TTY 711),
24 hours a day, 7 days a week (except closed holidays). If you cannot hear or speak well, please call
711.
Upon request, this document can be made available to you in braille, large print, audiocassette, or
electronic form. To obtain a copy in one of these alternative formats, or another format, call our
Member Service Contact Center and ask for the format you need.
How to file a grievance with Kaiser Permanente
You can file a discrimination grievance with Kaiser Permanente if you believe we have failed to
provide these services or unlawfully discriminated in another way. Please refer to your Evidence of
Coverage or Certificate of Insurance for details. You may also speak with a Member Services
representative about the options that apply to you. Please call Member Services if you need help
filing a grievance.
You may submit a discrimination grievance in the following ways:
• By phone: Call Member Services at 1 800-464-4000 (TTY 711) 24 hours a day, 7 days a
week (except closed holidays)
• By mail: Call us at 1 800-464-4000 (TTY 711) and ask to have a form sent to you
• In person: Fill out a Complaint or Benefit Claim/Request form at a member services office
located at a Plan Facility (go to your provider directory at kp.org/facilities for addresses)
• Online: Use the online form on our website at kp.org
You may also contact the Kaiser Permanente Civil Rights Coordinators directly at the addresses
below:
Attn: Kaiser Permanente Civil Rights Coordinator
Member Relations Grievance Operations
P.O. Box 939001
San Diego CA 92193
How to file a grievance with the California Department of Health Care Services Office of Civil
Rights
(For Medi-Cal Beneficiaries Only)
You can also file a civil rights complaint with the California Department of Health Care Services
Offi
ce of Civil Rights in writing, by phone or by email:
• By phone: Call DHCS Office of Civil Rights at 916-440-7370 (TTY 711)
• By mail: Fill out a complaint form or send a letter to:
Deputy Director, Office of Civil Rights
Department of Health Care Services
Office of Civil Rights
P.O. Box 997413, MS 0009
Sacramento, CA 95899-7413
Complaint forms are available at: http://www.dhcs.ca.gov/Pages/Language_Access.aspx
• Online: Send an email to [email protected]
How to file a grievance with the U.S. Department of Health and Human Services Office of
Civil Rights
You can file a discrimination complaint with the U.S. Department of Health and Human Services
Office for Civil Rights. You can file your complaint in writing, by phone, or online:
• By phone: Call 1-800-368-1019 (TTY 711 or 1-800-537-7697)
• By mail: Fill out a complaint form or send a letter to:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
Complaint forms are available at:
http:www.hhs.gov/ocr/office/file/index.html
• Online: Visit the Office of Civil Rights Complaint Portal at:
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf.
Aviso de no discriminación
La discriminación es ilegal. Kaiser Permanente cumple con las leyes de los derechos civiles
federales y estatales.
Kaiser Permanente no discrimina ilícitamente, excluye ni trata a ninguna persona de forma distinta
por motivos de edad, raza, identificación de grupo étnico, color, país de origen, antecedentes
culturales, ascendencia, religión, sexo, género, identidad de género, expresión de género,
orientación sexual, estado civil, discapacidad física o mental, condición médica, fuente de pago,
información genética, ciudadanía, lengua materna o estado migratorio.
Kaiser Permanente ofrece los siguientes servicios:
• Ayuda y servicios sin costo a personas con discapacidades para que puedan comunicarse
mejor con nosotros, como lo siguiente:
intérpretes calificados de lenguaje de señas,
información escrita en otros formatos (braille, impresión en letra grande, audio, formatos
electrónicos accesibles y otros formatos).
• Servicios de idiomas sin costo a las personas cuya lengua materna no es el inglés, como:
intérpretes calificados,
información escrita en otros idiomas.
Si necesita nuestros servicios, llame a nuestra Central de Llamadas de Servicio a los Miembros al
1-800-464-4000 (TTY 711) las 24 horas del día, los 7 días de la semana (excepto los días festivos).
Si tiene deficiencias auditivas o del habla, llame al 711.
Este documento estará disponible en braille, letra grande, casete de audio o en formato electrónico a
solicitud. Para obtener una copia en uno de estos formatos alternativos o en otro formato, llame a
nuestra Central de Llamadas de Servicio a los Miembros y solicite el formato que necesita.
Cómo presentar una queja ante Kaiser Permanente
Usted puede presentar una queja por discriminación ante Kaiser Permanente si siente que no le
hemos ofrecido estos servicios o lo hemos discriminado ilícitamente de otra forma. Consulte su
Evidencia de Cobertura (Evidence of Coverage) o Certificado de Seguro (Certificate of Insurance)
para obtener más información. También puede hablar con un representante de Servicio a los
Miembros sobre las opciones que se apliquen a su caso. Llame a Servicio a los Miembros si
necesita ayuda para presentar una queja.
Puede presentar una queja por discriminación de las siguientes maneras:
• Por teléfono: llame a Servicio a los Miembros al 1 800-464-4000 (TTY 711), las 24 horas
del día, los 7 días de la semana (excepto los días festivos).
• Por correo postal: llámenos al 1 800-464-4000 (TTY 711) y pida que se le envíe un
formulario.
• En persona: llene un formulario de Queja o reclamación/solicitud de beneficios en una
oficina de Servicio a los Miembros ubicada en un centro del plan (consulte su directorio de
proveedores en kp.org/facilities [cambie el idioma a español] para obtener las direcciones).
• En línea: utilice el formulario en línea en nuestro sitio web en kp.org/espanol.
También puede comunicarse directamente con el coordinador de derechos civiles (Civil Rights
Coordinator) de Kaiser Permanente a la siguiente dirección:
Attn: Kaiser Permanente Civil Rights Coordinator
Member Relations Grievance Operations
P.O. Box 939001
San Diego CA 92193
Cómo presentar una queja ante la Oficina de Derechos Civiles del Departamento de Servicios
de Atención Médica de California (Solo para beneficiarios de Medi-Cal)
También puede presentar una queja sobre derechos civiles ante la Oficina de Derechos Civiles
(Office of Civil Rights) del Departamento de Servicios de Atención Médica de California
(California Department of Health Care Services) por escrito, por teléfono o por correo electrónico:
• Por teléfono: llame a la Oficina de Derechos Civiles del Departamento de Servicios de
Atención Médica (Department of Health Care Services, DHCS) al 916-440-7370 (TTY 711).
• Por correo postal: llene un formulario de queja o envíe una carta a:
Deputy Director, Office of Civil Rights
Department of Health Care Services
Office of Civil Rights
P.O. Box 997413, MS 0009
Sacramento, CA 95899-7413
Los formularios de queja están disponibles en:
http://www.dhcs.ca.gov/Pages/Language_Access.aspx (en inglés).
• En línea: envíe un correo electrónico a [email protected].
Cómo presentar una queja ante la Oficina de Derechos Civiles del Departamento de Salud y
Servicios Humanos de los EE. UU.
Puede presentar una queja por discriminación ante la Oficina de Derechos Civiles del Departamento
de Salud y Servicios Humanos de EE. UU. (U.S. Department of Health and Human Services).
Puede presentar su queja por escrito, por teléfono o en línea:
• Por teléfono: llame al 1-800-368-1019 (TTY 711 o al 1-800-537-7697).
• Por correo postal: llene un formulario de queja o envíe una carta a:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
Los formularios de quejas están disponibles en
http://www.hhs.gov/ocr/office/file/index.html (en inglés).
• En línea: visite el Portal de quejas de la Oficina de Derechos Civiles en:
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
(en inglés).
反歧視聲明反
歧視是違反法律的行為。Kaiser Permanente遵守州政府與聯邦政府的民權法。
Kaiser Permanente不因年齡、人種、族群認同、膚色、原國籍、文化背景、祖籍、宗教、生
理性別、社會性別、性認同、性表現、性取向、婚姻狀況、身體或精神殘障、病況、付款來
源、遺傳資訊、公民身份、母語或移民身份而非法歧視、排斥或差別對待任何人。
Kaiser Permanente提供下列服務：
• 為殘障人士提供免費協助與服務以幫助其更好地與我們溝通，例如：
合格手語翻譯員
其他格式的書面資訊（盲文版、大字版、語音版、通用電子格式及其他格式）
• 為母語非英語的人士提供免費語言服務，例如：
合格口譯員
其他語言的書面資訊
如果您需要上述服務，請打電話1-800-464-4000 (TTY 711) 給會員服務聯絡中心，每週7天，
每天24小時（節假日除外）。如果您有聽力或語言困難，請打電話711。
若您提出要求，我們可為您提供本文件的盲文版、大字版、錄音卡帶或電子格式。如要得到
上述一種替代格式或其他格式的版本，請打電話給會員服務聯絡中心並索取您需要的格式。
如何向Kaiser Permanente投訴
如
投訴
如果您認為我們未能提供上述服務或有其他形式的非法歧視行為，您可向Kaiser Permanente
提出歧視投訴。請參閱您的《承保範圍說明書》(Evidence of Coverage) 或《保險證明》
(Certificate of Insurance) 瞭解詳情。您也可以向會員服務部代表諮詢適用於您的選項。如果
您在投訴時需要協助，請打電話給會員服務部。
您可透過下列方式投訴歧視：
• 電電話：打電話1 800-464-4000 (TTY 711) 聯絡會員服務部，每週7天，每天24小時（節
假日除外）
• 郵
親自提出：
郵寄：打電話1 800-464-4000 (TTY 711) 與我們聯絡，要求將投訴表寄給您
• 親自提出：在保險計劃下屬設施的會員服務辦公室填寫投訴或索賠／申請表（請在
kp.org/facilities網站的保健業者名錄上查詢地址）
• 線線上：使用kp.org網站上的線上表格
歧視聲明
何向
話：
寄：
上：
如何向加州保健服務部民權辦公室投訴
您也可直接與Kaiser Permanente民權事務協調員聯絡，地址如下：
Attn: Kaiser Permanente Civil Rights Coordinator
Member Relations Grievance Operations
P.O. Box 939001
San Diego CA 92193
如何向加州保健服務部民權辦公室投訴（僅限Medi-Cal受益人）
您也可透過書面方式、電話或電子郵件向加州保健服務部民權辦公室提出民權投訴：
• 電話：電話：打電話916-440-7370 (TTY 711) 聯絡保健服務部 (DHCS) 民權辦公室
• 郵寄：郵寄：填寫投訴表或寄信至：
Deputy Director, Office of Civil Rights
Department of Health Care Services
Office of Civil Rights
P.O. Box 997413, MS 0009
Sacramento, CA 95899-7413
您可在網站上http://www.dhcs.ca.gov/Pages/Language_Access.aspx取得投訴表
• 線上：
如何向美國健康與民眾服務部民權辦公室投訴
線上：發送電子郵件至[email protected]
如何向美國健康與民眾服務部民權辦公室投訴
您可向美國健康與民眾服務部民權辦公室提出歧視投訴。您可透過書面、電話或線上提出投
訴：
• 電話：電話：打電話1-800-368-1019（TTY 711或1-800-537-7697）
• 郵寄：郵寄：填寫投訴表或寄信至：
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
您可在網站上取得投訴表：
http:www.hhs.gov/ocr/office/file/index.html取得投訴表
• 線 ：線上：訪問民權辦公室投訴入口網站： 上
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
。
。
Thông Báo Không Phân Biệt Đối Xử
Phân bit đi x là trái vi pháp lut. Kaiser Permanente tun thủ cc lut dn quyền của Tiểu Bang
và Liên Bang.
Kaiser Permanente không phn bit đi x tri php lut, loại trừ hay đi x khc bit vi người
no đó vì lý do tuổi tc, chủng tộc, nhn dạng nhóm sắc tộc, mu da, nguồn gc quc gia, nền tảng
văn hóa, tổ tiên, tôn gio, gii tính, nhn dạng gii tính, cch thể hin gii tính, khuynh hưng gii
tính, tình trạng hôn nhn, tình trạng khuyết tt về thể chất hoặc tinh thần, bnh trạng, nguồn thanh
ton, thông tin di truyền, quyền công dn, ngôn ngữ mẹ đẻ hoặc tình trạng nhp cư.
Kaiser Permanente cung cấp cc dịch vụ sau:
• Phương tin hỗ trợ v dịch vụ miễn phí cho người khuyết tt để giúp họ giao tiếp hiu quả
hơn vi chúng tôi, chẳng hạn như:
Thông dịch viên ngôn ngữ ký hiu đủ trình độ
Thông tin bằng văn bản theo cc định dạng khc (chữ nổi braille, bản in khổ chữ ln, m
thanh, định dạng đin t dễ truy cp v cc định dạng khc)
• Dịch vụ ngôn ngữ miễn phí cho những người có ngôn ngữ chính không phải l tiếng Anh,
chẳng hạn như:
Thông dịch viên đủ trình độ
Thông tin được trình by bằng các ngôn ngữ khc
Nếu quý vị cần những dịch vụ ny, xin gọi đến Trung Tm Liên Lạc ban Dịch Vụ Hội Viên của
chúng tôi theo s 1-800-464-4000 (TTY 711), 24 giờ trong ngy, 7 ngy trong tuần (đóng ca ngy
lễ). Nếu quý vị không thể nói hay nghe rõ, vui lòng gọi 711 .
Theo yêu cầu, ti liu ny có thể được cung cấp cho quý vị dưi dạng chữ nổi braille, bản in khổ
chữ ln, băng thu m hay dạng đin t. Để lấy một bản sao theo một trong những định dạng thay
thế ny hay định dạng khc, xin gọi đến Trung Tm Liên Lạc ban Dịch Vụ Hội Viên của chúng tôi
v yêu cầu định dạng m quý vị cần.
Cách đệ trình phàn nàn với Kaiser Permanente
Quý vị có thể đ trình phn nn về phn bit đi x vi Kaiser Permanente nếu quý vị tin rằng
chúng tôi đã không cung cấp những dịch vụ ny hay phn bit đi x tri php lut theo cch khc.
Vui lòng tham khảo Chứng Từ Bảo Hiểm (Evidence of Coverage) hay Chứng Nhận Bảo Hiểm
(Certificate of Insurance) của quý vị để biết thêm chi tiết. Quý vị cũng có thể nói chuyn vi nhn
viên ban Dịch Vụ Hội Viên về những lựa chọn p dụng cho quý vị. Vui lòng gọi đến ban Dịch Vụ
Hội Viên nếu quý vị cần được trợ giúp để đ trình phn nn.
Quý vị có thể đ trình phn nn về phn bit đi x bằng cc cch sau đy:
• Qua điện thoại: Gọi đến ban Dịch Vụ Hội Viên theo s 1-800-464-4000 (TTY 711) 24 giờ
trong ngy, 7 ngy trong tuần (đóng ca ngy lễ)
• Qua thư tín: Gọi chúng tôi theo s 1-800-464-4000 (TTY 711) v yêu cầu gi mẫu đơn
cho quý vị
• Trực tiếp: Hon tất mẫu đơn Than Phiền hay Yêu Cầu Thanh Ton/Yêu Cầu Quyền Lợi tại
văn phòng dịch vụ hội viên ở một Cơ Sở Thuộc Chương Trình (truy cp danh mục nh cung
cấp của quý vị tại kp.org/facilities để biết địa chỉ)
• Trực tuyến: S dụng mẫu đơn trực tuyến trên trang mạng của chúng tôi tại kp.org
Quý vị cũng có thể liên h trực tiếp vi Điều Phi Viên Dn Quyền của Kaiser Permanente theo địa
chỉ dưi đy:
Attn: Kaiser Permanente Civil Rights Coordinator
Member Relations Grievance Operations
P.O. Box 939001
San Diego CA 92193
Cách đệ trình phàn nàn với Văn Phòng Dân Quyền Ban Dịch Vụ Y Tế California (Dành Riêng
Cho Người Thụ Hưởng Medi-Cal)
Quý vị cũng có thể đ trình than phiền về dn quyền vi Văn Phòng Dn Quyền Ban Dịch Vụ Y Tế
California bằng văn bản, qua đin thoại hay qua email:
• Qua điện thoại: Gọi đến Văn Phòng Dn Quyền Ban Dịch Vụ Y Tế (Department of Health
Care Services, DHCS) theo s 916-440-7370 (TTY 711)
• Qua thư tín: Điền mẫu đơn than phiền v hay gi thư đến:
Deputy Director, Office of Civil Rights
Department of Health Care Services
Office of Civil Rights
P.O. Box 997413, MS 0009
Sacramento, CA 95899-7413
Mẫu đơn than phiền hin có tại: http://www.dhcs.ca.gov/Pages/Language_Access.aspx
• Trực tuyến: Gi email đến [email protected]
Cách đệ trình phàn nàn với Văn Phòng Dân Quyền của Bộ Y Tế và Dịch Vụ Nhân Sinh Hoa Kỳ.
Quý vị cũng có quyền đ trình than phiền về phn bit đi x vi Văn Phòng Dn Quyền của Bộ Y
Tế v Dịch Vụ Nhn Sinh Hoa Kỳ. Quý vị có thể đ trình than phiền bằng văn bản, qua đin thoại
hoặc trực tuyến:
• Qua điện thoại: Gọi 1-800-368-1019 (TTY 711 hay 1-800-537-7697)
• Qua thư tín: Điền mẫu đơn than phiền v hay gi thư đến:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
Mẫu đơn than phiền hin có tại
http:www.hhs.gov/ocr/office/file/index.html
• Trực tuyến: Truy cp Cổng Thông Tin Than Phiền của Văn Phòng Dn Quyền tại:
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf.
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. You can
also request auxiliary aids and
devices at our facilities.
Just call us at 1-800-464-4000,
24 hours a day, 7 days a week
(closed holidays). TTY users
call 711.
Arabic:
1-800-464-4000
711
Armenian: Ձեզ կարող է անվճ
ար օգնություն
տրամադրվել լեզվի հարցում` օրը 24 ժամ,
շաբաթը 7 օր: Դուք կարող եք պահանջել
բանավոր թարգմանչի ծառայություններ, Ձեր
լեզվով թարգմանված կամ այլընտրանքային
ձևաչափով պատրաստված նյութեր: Դուք նաև
կարող եք խնդրել օժանդակ օգնություններ և
սարքեր մեր հաստատություններում:
Պարզապես զանգահարեք մեզ 1-800-464-4000
հեռախոսահամարով` օրը 24 ժամ, շաբաթը 7 օր
(տոն օրերին փակ է): TTY-ից օգտվողները պետք
է զանգահարեն 711:
Chinese: 您每週 7 天，每天 24 小時均可獲得免費語
言協助。您可以
申請口譯服務、要求將資料翻譯成您
所用語言或轉換為其他格式。您還可以在我們的場所
內申請使用輔助工具和設備。我們每週 7 天，每天 24
小時均歡迎您打電話 1-800-757-7585 前來聯絡（節假
日休息）。聽障及語障專線 (TTY) 使用者請撥 711。
Farsi:
.
. 24
1-800-464-4000
TTY
711
Hindi:
24
-
1-800-464-4000 24
TTY
711
Hmong: Muaj kec 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. Koj kuj
thov tau lwm yam kev pab thiab khoom siv hauv peb tej
tsev hauj lwm. 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: 当院では、言語支援を無料で、年中無休、
終日ご利用いただけます。通訳サービス、日本語に
翻訳された資料、あるいは資料を別の書式でも依頼
できます。
補助サービスや当施設の機器について
もご相談いただけます。
お気軽に 1-800-464-4000
までお電話ください（祭日を除き年中無休）。
TTY ユーザーは 711 にお電話ください。
Khmer:
24
7
1-800-464-4000
24
7
() TTY 711
Korean: 요일 및 시간에 관계없이 언어지원
서비스를 무료로 이용하실 수 있습니다. 귀하는
통역 서비스,귀하의 언어로 번역된 자료 또는 대체
형식의 자료를 요청할 수 있습니다. 또한 저희
시설에서 보조기구 및 기기를 요청하실 수
있습니다. 요일 및 시간에 관계없이
1-800-464-4000 번으로 전화하십시오 (공휴일휴무).
TTY 사용자번호 711.
Laotian:
,
24
, 7
.
,
,
.
ທ່ານສາມາດຂໍ ອ
ຸ
ປະກອນຊ່ວຍເສີ ມ ແລະ ອ
ຸ
ປະກອນ
ຕ່າງໆໃນສະຖານບໍ ລິ ການຂອງພວກເ ຮົ າ ໄດ້ .
1-800-464-4000,
24
, 7
( ).
TTY
711.
Mien: Mbenc nzoih liouh wang-henh tengx nzie faan
waac bun muangx maiv zuqc cuotv zinh nyaanh meih,
yietc hnoi mbenc maaih 24 norm ziangh hoc, yietc
norm liv baaiz mbenc maaih 7 hnoi. Meih se haih tov
heuc tengx lorx faan waac mienh tengx faan waac bun
muangx, dorh nyungc horngh jaa-sic mingh faan benx
meih nyei waac, a'fai liouh ginv longc benx haaix hoc
sou-guv daan yaac duqv. Meih corc haih tov longc
benx wuotc ginc jaa-dorngx tengx aengx caux jaa-sic
nzie bun yiem njiec zorc goux baengc zingh gorn
zangc. Kungx douc waac mingh lorx taux yie mbuo
yiem njiec naaiv 1-800-464-4000, yietc hnoi mbenc
maaih 24 norm ziangh hoc, yietc norm liv baaiz mbenc
maaih 7 hnoi. (hnoi-gec se guon gorn zangc oc).
TTY nyei mienh nor douc waac lorx 711.
Navajo: Doo bik’é asíníłáágóó saad bee ata’ hane’ bee
áká e’elyeed nich’į’ ąą’át’é, t’áá áłahjį’ jí֖i֖go dóó
tł’ée’go áádóó tsosts’íjí ąą’át’é. Ata’ hane’ yídííkił,
naaltsoos t’áá Diné bizaad bee bik’i’ ashchíigo, éí
doodago hane’ bee didííts’ííłígíí yídííkił. Hane’ bee
bik’i’ di’díítííłígíí dóó bee hane’ didííts’ííłígíí
bína’ídíłkidgo yídííkił. Koj̨í hodiilnih 1-800-464-4000,
t’áá áłahjį’, jí
֖
i
֖
֖go dóó tł’ée’go áádóó tsosts’íjí ąą’át’é.
(Dahodílzingóne’ doo nida’anish dago éí da’deelkaal).
TTY chodayooł’ínígíí koj̨í dahalne’ 711.
Punjabi: , 24 ,
7 ,
,
,
1-800-464-4000 , 24 ,
7 TTY
711 ‘
Russian: Мы бесплатно обеспечиваем Вас услугами
п
еревода 24 часа в сутки, 7 дней в неделю. Вы можете
воспользоваться помощью устного переводчика,
запросить перевод материалов на свой язык или
запросить их в одном из альтернативных форматов.
Мы также можем помочь вам с вспомогательными
средствами и альтернативными форматами. Просто
позвоните нам по телефону 1-800-464-4000, который
доступен 24 часа в сутки, 7 дней в неделю (кроме
праздничных дней). Пользователи линии TTY могут
звонить по номеру 711.
Spanish: Tenemos disponible asistencia en su idioma
sin
ningún costo para usted 24 horas al día, 7 días a la
semana. Puede solicitar los servicios de un intérprete,
que los materiales se traduzcan a su idioma o en
formatos alternativos. También puede solicitar recursos
para discapacidades en nuestros centros de atención.
Solo llame al 1-800-788-0616, 24 horas al día, 7 días a
la semana (excepto los días festivos). Los usuarios de
TTY, deben llamar al 711.
Tagalog: May magagamit na tulong sa wika nang wala
kang ba
bayaran, 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. Maaari ka ring
humiling ng mga karagdagang tulong at device sa
aming mga pasilidad. 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
7
1-800-464-4000
24
7()
TTY 711
Ukrainian: Послуги перекладача надаються
б
езкоштовно, цілодобово, 7 днів на тиждень. Ви
можете зробити запит на послуги усного
перекладача, отримання матеріалів у перекладі
мовою, якою володієте, або в альтернативних
форматах. Також ви можете зробити запит на
отримання допоміжних засобів і пристроїв у
закладах нашої мережі компаній. Просто
зателефонуйте нам за номером 1-800-464-4000.
Ми працюємо цілодобово, 7 днів на тиждень
(крім святкових днів). Номер для користувачів
телетайпа: 711.
Vietnamese: Dịch vụ thông dịch được cung cấp miễn
phí c
ho quý vị 24 giờ mỗi ngày, 7 ngày trong tuần. Quý
vị có thể yêu cầu dịch vụ thông dịch, tài liệu phiên dịch
ra ngôn ngữ của quý vị hoặc tài liệu bằng nhiều hình
thức khác. Quý vị cũng có thể yêu cầu các phương tiện
trợ giúp và thiết bị bổ trợ tại các cơ sở của chúng tôi.
Quý vị chỉ cần gọi cho chúng tôi tại số 1-800-464-4000,
24 giờ mỗi ngày, 7 ngày trong tuần (trừ các ngày lễ).
Người dùng TTY xin gọi 711.
1086774819 California 2024
