1. I have at least 18 months of creditable coverage without a break in coverage of more than 63 days at any time.
2. My most recent health care coverage was through a group health plan, governmental plan, or church plan.
3. I have both elected and exhausted all continuation health care coverage available under federal (COBRA) and state continuation coverage laws.
4. I do not currently have other health care coverage and I am not eligible for coverage under any group health plan, governmental plan, church plan, state-administered Medicaid program, or Medicare.
5. My most recent coverage was NOT terminated for fraud or failure to pay premiums.

The benefits are the same, but for Kaiser Permanente HIPAA Plans rates are 170 percent of Kaiser Permanente for Individuals and Families plan rates.

1. To be eligible for a Kaiser Permanente HIPAA Plan, you must meet all of the above eligibility requirements.
2. Review the Evidence of Coverage for your coverage benefits and HIPAA rates.
3. Print, complete, and sign the entire Kaiser Permanente for Individuals and Families Application that includes a HIPAA Eligibility Questionnaire and Request for Enrollment section. (You will be able to print your completed application immediately after submitting it online.) Note: If you are not applying for Kaiser Permanente for Individuals and Families, you should print, complete, and sign the separate Kaiser Permanente HIPAA Plan Enrollment Application.
4. Include a Certificate(s) of Creditable Coverage or other evidence of creditable coverage from previous employer(s) or provider(s) of health care coverage, and mail this along with your application.

Please send the completed application to the following address:

California Service Center
Kaiser Permanente
P.O. Box 23059
San Diego, CA 92193-9922