Form Validation Matrix - Kaiser Permanente

Forms validation matrix

Help avoid processing delays by fully completing and submitting the most current forms. Our forms are updated periodically to comply with the most recent legal and regulatory requirements. This matrix is segmented into sections; New Business, Existing Groups and Recertification, so you can easily reference what you need.

To ensure you're using a valid form, please reference the 8-digit order tracking number (OTN) located on the lower lefthand corner of the last page of each form and reference against the OTNs below and the expiration date. Forms not listed on this matrix are outdated and won't be accepted for processing. Remember, you can always find the current forms at smallbusinessbrokerforms/ca.*

* Forms followed by this indicator aren't accessible on account.. For forms that aren't available online, please contact our Small Business Services Customer Connection Team at 800-790-4661, option 3 for consultation.

NEW BUSINESS Form name Click form name to download the most current version

Census, Broker Census, Broker Census, Employer (Direct)

Declination of Coverage, English Declination of Coverage, English Declination of Coverage, Chinese

Declination of Coverage, Chinese Declination of Coverage, Spanish Declination of Coverage, Spanish Electronic Transfer for Payment

Small Business 2020 January

Version

January 2020 January 2018 January 2017 January 2020 January 2019 January 2020 January 2019 January 2020 January 2019 January 2020

Order tracking Expiration number (OTN) date

373250464 60645108 60515208 362735382 61134709 375057219 61187109 375056445 61186910 365799621

12.31.19

12.31.19 12.31.19 12.31.19

NEW BUSINESS cont. Form name Click form name to download the most current version

Employee Enrollment, English Employee Enrollment, English Employee Enrollment, Chinese Employee Enrollment, Chinese Employee Enrollment, Spanish Employee Enrollment, Spanish Employer Attestation Declination of Coverage Employer Attestation Declination of Coverage New Employee Eligibility New Employee Eligibility 2020 New Group Application 2019 New Group Application Owner/Officer Eligibility Statement Owner/Officer Eligibility Statement

EXISTING GROUP Form name Click form name to download the most current version

Change of Ownership Change of Ownership Change of Ownership Subscriber Transfer Change of Ownership Subscriber Transfer

Small Business 2020 January

Version

January 2020 July 2019 January 2020 July 2019_v2 January 2020 July 2019_v2 January 2020 January 2019 January 2020 January 2019 January 2020 January 2019 January 2020 January 2019

Order tracking Expiration number (OTN) date

362713619 345232931 375064459 61187209 375062300 61187110 362747443 61134908 362741655 61134810 346554401 61153408 365803302 61135308

12.31.19 12.31.19 12.31.19 12.31.19 12.31.19 12.31.19 12.31.19

Version

January 2020 January 2019 January 2020 January 2019

Order tracking Expiration number (OTN) date

373257811 61134308 373257811 61134408

12.31.19 12.31.19

EXISTING GROUP cont.

Form name Click form name to download the most current version

Change of Ownership / Change of Ownership Subscriber Transfer Combination Change of Ownership / Change of Ownership Subscriber Transfer Combination Contact Change Request

Contact Change Request Customer Address or Name Change Request

Customer Address or Name Change Request Electronic Transfer for Payment

Employee Dependent Change, English

Employee Dependent Change, English Employee Dependent Change, Chinese

Employee Dependent Change, Chinese Employee Dependent Change, Spanish

Employee Dependent Change, Spanish Employee Enrollment, English

Employee Enrollment, English Employee Enrollment, Chinese

Employee Enrollment, Chinese Employee Enrollment, Spanish

Employee Enrollment, Spanish Grandfathered (Nonmetal) Health Plan(s) Status Grandfathered (Nonmetal) Health Plan(s) Status Group Termination Request Group Termination Request

Small Business 2020 January

Version

January 2020

January 2019

January 2020 January 2019 January 2020 January 2019 January 2020 January 2020 July 2019 January 2020 July 2019_v2 January 2020 July 2019_v2 January 2020 July 2019 January 2020 July 2019_v2 January 2020 July 2019_2 January 2020 January 2019 January 2020 January 2019

Order tracking Expiration number (OTN) date

373257811

61134308 and 61134408 381232732 61134508 381257973 61134708 365799621 368443377 345227196

12.31.19 12.31.19 12.31.19 12.31.19

61187110

12.31.19

61187308 362713619 345232931

12.31.19 12.31.19

61187209

12.31.19

61187110 380765396 61134809 380771714 61134909

12.31.19 12.31.19 12.31.19

EXISTING GROUP cont. Form name Click form name to download the most current version

2020 New Group Application 2019 New Group Application 2018 New Group Application Primary Administrator Online Access Online Account Services User ID Request 2020 Plan Add/Change Request 2019 Plan Add/Change Request 2018 Plan Add/Change Request Renewal Date Change Request Renewal Date Change Request Special Open Enrollment Request Special Open Enrollment Request Subscriber Termination and Transfer Subscriber Termination and Transfer

RECERTIFICATION Form name Click form name to download the most current version

Contact Change Request Contact Change Request Customer Address or Name Change Request Customer Address or Name Change Request

Small Business 2020 January

Version

January 2020 January 2019 January 2018 January 2020 July 2019 January 2020 January 2019 January 2018 January 2020 January 2019 January 2020 January 2019 January 2020 July 2019

Order tracking Expiration number (OTN) date

346554401

61153408 60596315 365805145

357088953 380711134

61135608 60757108 380770298

61135409 381238398 61135808 381238398 345235546

12.31.20 12.31.19

12.31.19

12.31.20 12.31.19

12.31.19 12.31.19 12.31.19

Version

January 2020 January 2019 January 2020 January 2019

Order tracking Expiration number (OTN) date

381232732 61134508 381257973 61134708

12.31.19 12.31.19

RECERTIFICATION cont.

Form name Click form name to download the most current version

Declination of Coverage, English

Declination of Coverage, English Declination of Coverage, Chinese

Declination of Coverage, Chinese Declination of Coverage, Spanish

Declination of Coverage, Spanish Employee/Dependent Change, English Employee/Dependent Change, English Employee/Dependent Change, Chinese Employee/Dependent Change, Chinese Employee/Dependent Change, Spanish Employee/Dependent Change, Spanish Employee Enrollment, English Employee Enrollment, English Employee Enrollment, Chinese Employee Enrollment, Chinese Employee Enrollment, Spanish Employee Enrollment, Spanish Employer Attestation Declination of Coverage Employer Attestation Declination of Coverage Employer's Confirmation of Workers' Compensation Employer's Confirmation of Workers' Compensation New Employee Eligibility New Employee Eligibility

Version

January 2020 January 2019 January 2020 January 2019 January 2020 January 2019 January 2020 July 2019 January 2020 July 2019_v2 January 2020 July 2019_v2 January 2020 July 2019 January 2020 July 2019_v2 January 2020 July 2019_v2 January 2020 January 2019 January 2020 January 2019 January 2020 January 2019

Order tracking Expiration number (OTN) date

362735382 61134709

12.31.19

61187109

12.31.19

61186910 368443377 345227196

12.31.19 12.31.19

61187110

12.31.19

61187308 362713619 345232931

12.31.19 12.31.19

61187209

12.31.19

61187110 362747443 61134908 380767749 61134511 362741655 61134810

12.31.19 12.31.19 12.31.19 12.31.19

Small Business 2020 January

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