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Apply for coverage from KPS Health Plans
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KPS
Health Plans Enrollment Form | KPS
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Application Process and Forms
To apply for any of the KPS Health Plans individual medical plans, please
complete the following steps:
- Fill out the Application (one per family)
Click
here to download the KPS Individual/Family Enrollment Application.
Print the application and fill it out completely.
- 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.
- 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
- 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 KPS Health Plans.
- Payment must be sent with your application
- Send all Enrollment Materials to:
CDA Insurance Services
P.O. Box 26540
Eugene, OR 97402
Please note: KPS Health Plans requires all COMPLETED
enrollment materials to be postmarked to their office on or before the 20th
of the month. Incomplete enrollments may cause delays in the effective date
of your coverage. Please refer to the checklist on the application to avoid
delays.
For Example: If you wanted your medical insurance coverage
to begin on July 1, you would need to send all of the required, completed
enrollment material to KPS Health Plans postmarked on or before June 20.
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