Apply with Kaiser Permanente Georgia

Apply Online

Print Application

• You will need Adobe Reader to download the paper request for enrollment.
• Paper applications may be used for a family of up to five. Larger families may use an additional form(s).
• Paper applications may be submitted one of three ways:
  • Fax: 1-866-439-9993
  • Email: Support@KaiserQuotes.com
  • Mail: KaiserQuotes.com, 750 Mendocino Avenue, Suite 4, Santa Rosa, CA 95401

Before You Start

The Kaiser Permanente Georgia application consists of 18 questions about your health and takes about 15 minutes to complete. Before you sit down to fill out the form, it will be helpful for you to have the following information handy:

• Social Security number for each applying family member.
• Prescription(s), if any.
• The doctor’s contact information if you received treatment.

Deadlines and Effective Dates

You can select to have an effective date of either the 1st or the 15th of the month. To qualify for a start date of the 1st of the month, a completed application must be received by the 25th of the month prior. For an effective date of the 15th, a completed application must be submitted by no later than the 10th of the same month.

Family Applications

A family of two or more members may apply together under one enrollment form. If not everyone is approved, you have the option of either having just the eligible members approved, or cancelling the application for the whole family.

Children under age 19 cannot apply on a single subscriber basis, however, kids up to age 26 can be included on a family application.

Pre-existing Conditions

If you have a pre-existing medical condition, there is a possibility that you may be denied or that the premium may be adjusted to include a surcharge. The rate-up, if any, will vary and will be based on the severity of the medical condition. If a surcharge is applied, you will be notified and given the opportunity to accept or decline enrollment.

Please be aware that in cases of a family application where a parent is ineligible for private health insurance and the remaining family member(s) on the application is a child or children under age 19, the application will be cancelled.

Payment Required for Activation

The application will ask how you would like to pay the initial premium. Payment may be made by including credit card information, or asking to be billed later. Either way, you will not be charged until the application is approved.

After the initial billing, future invoices can be paid via:

• Automatic Draft Plan (payments will be automatically deducted from your bank account)
• Debit/Credit Card
• Paper invoice

You can change the payment method or billing address by making arrangements with the Kaiser Permanente Billing Department.

Note that enrollment is month-to-month, so you can cancel at any time. You are not required to carry the Kaiser Permanente insurance for any length of time beyond one month.

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