Employee Forms
	HIPPA Authorization Disclosure Form - HealthNet This Authorization is required for the use or disclosure of your PHI beyond uses and disclosures for payment, treatment or health care operations., 2 Pages
	Kaiser Permanente Choice Solution Employee Change Request Form For effective dates 10/1/2010 to 12/1/2010 Used to update personal information or to add/cancel coverage. (not for plan or provider changes), 3 Pages (Rev. 6-10)
	Kaiser Permanente Choice Solution Employee Change Request Form For employees to update personal information or to add/cancel coverage. Not for plan or provider changes. , 3 Pages (Rev. 4/09)
	Kaiser Permanente Choice Solution Employee Health Questionnaire To be completed by employees in a group with only 2-14 medically enrolled employees., 2 Pages (Rev. 10/06)
	Kaiser Permanente Choice Solution Full-Time Student Verification 1 Page (Rev. 6-09)
	Kaiser Permanente Choice Solution Renewal Change Request Form For effective dates 10/1/2010 to 12/1/2010 Used to update personal information or to add/cancel coverage. (not for plan or provider changes), 3 Pages (Rev. 6-10)
	Kaiser Permanente Choice Solution Renewal Change Request Form For employees to update information and change benefits and/or plan designs during Open Enrollment Only. , 3 Pages (Rev. 9/09)
	Kaiser Permanente Choice Solutions Employee Application For effective dates 10/1/2010 to 12/1/2010 For employees to enroll in the Kaiser Permanente Choice Solution program., 4 Pages (Rev. 6-10)
	Kaiser Permanente Choice Solutions Employee Application Medical / Dental / Life / Enrollment Application, 4 Pages (Rev. 9-09)
	Kaiser Permanente Employee Termination Notification Form Complete this form when there is a termination of employment, reduction of hours or loss of life. Coverage will end on the last day of the month following each event., 1 Page (Rev. 10-09)
	Kaiser Permanete Medical Claim Form Used for submission of medical Claims, 2 Pages (Rev. 02-06)
	Language Assistance Program Form Members use to request Language Assistance Services Program, allowing interpretation of services and documents into certian languages. , 2 Pages (Rev. 09-09)

Benefit Summaries
	Kaiser Permanente Choice Solution Benefit Summaries For effective dates 1/1/2010 to 6/1/2010 Benefit summaries for all medical plans., 11 Pages (Rev. 12-09)
	Kaiser Permanente Choice Solution Benefit Summaries For effective dates 7/1/2010 to 12/1/2010 Benefit summaries for all medical plans., 11 Pages (Rev. 3-10)

Employer Forms
	Kaiser Permanente Choice Solution Master Employer Application Required for all new groups applying for coverage., 4 Pages (Rev. 9-09)
	Kaiser Permanente Choice Solution Employer Administration Handbook This Employer Administrative Handbook is intended to guide you through different administrative procedures, as well as answer general questions about the Kaiser Permanente Choice Solution offering., 42 Pages (Rev. 9-09)
	Kaiser Permanente Choice Solution Employer Change Request For the Employer to request Off-Anniversary or Open Enrollment Only changes to the group's policy, 2 Pages (Rev. 9-09)
	Kaiser Permanente Choice Solution Owner-Partner Statement 1 Page (Rev. 12-07)

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For additional information, please contact Claremont at 800.696.4543 or info@claremontcompanies.com