Kaiser Permanente - Individuals and Families

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Plan Benefits
Silver Plans | Silver Plans with Rx
Plan Premiums
Silver $4,000 | Silver $6,000 | Silver Rx $500 | Silver Rx $1,000 | Silver Rx $2,500

Application Process and Forms

To apply for any of the Kaiser Permanente individual medical plans, please complete the following steps:

1. Fill out the Application (one per family)
   Click here to download the Kaiser Permanente Individual/Family Enrollment Application. Print the application and fill it out completely.
   
   
2. Fill out the Questionnaire (one for each person to be covered)
   Click here to download the Standard Health Questionnaire for Washington State. Print and complete the questionnaire for each person to be covered on the plan. Please refer to Completing the Health Questionnaire to determine if this applies.
   
   
3. Provide Proof of Washington State Residency
   To be eligible to purchase this plan you must be a Washington state resident.
   A photocopy of one of the following must accompany your application to prove residency:
   
   • Valid Washington State Driver's License or Identification Card
   • Washington State Voter Registration Card
   • Current Utility Bill in your name, including address


4. Provide Certificate of Creditable Coverage (if available)
   Please refer to Credit for Prior Coverage & HIPAA Eligibility for more information. Please note, if you do not have your Certificate of Creditable Coverage at the time of application, please submit your application anyway. Credit for pre-existing condition waiting periods will be credited upon receipt of your Certificate of Creditable Coverage by Kaiser Permanente.
   
   
5. Do not Send a Payment
   Please do not send a rate payment with your application. You will receive a statement from Kaiser Permanente upon acceptance of your application.
   
   
6. Send all Enrollment Materials to:
   CDA Insurance Services
   P.O. Box 26540
   Eugene, OR 97402