The Kaiser Permanente account change form is a fillable PDF that members with Individual and Family Plans use to update personal details or change who is covered under their policy. Download the version for your state from the “Change Your Plan Information” page at healthy.kaiserpermanente.org/support/change-plan-information, fill in the sections that apply to your change, attach any required documentation, and send the packet to Membership Administration by mail or fax. The form handles the structural updates you cannot make through a quick online message: name corrections, adding or removing dependents, switching the subscriber, and ending coverage.
When You Need the Form
Not every account update calls for this form. A mailing address change can be handled by sending a message to Member Services through kp.org with the subject line “other,” listing the new address and the names of everyone on the plan. For anything that touches your name, date of birth, Social Security number, or gender, you need the account change form.
The same form covers changes to who is on your plan. Common reasons members file one:
- Adding a spouse or domestic partner after marriage or a new domestic partnership.
- Adding a newborn or adopted child.
- Removing a dependent after divorce, a child aging out, or the end of a domestic partnership.
- Changing plans during open enrollment or after a qualifying life event.
- Switching the subscriber on a family account, for example when the current subscriber is dropping coverage but wants a spouse to take over.
- Ending coverage for yourself or a family member.
Who Shouldn’t Use This Form
If you bought your Kaiser plan through a Health Insurance Exchange such as Covered California or the federal Marketplace, you don’t use this form at all. Contact the exchange directly to update your records, and the exchange notifies Kaiser.
Medicare members update their information through the Social Security Administration and Kaiser’s Medicare Department. Medi-Cal and Medicaid members report changes to their county or state agency, which then notifies Kaiser.
Where to Get the Right Version
Kaiser publishes a separate PDF for each state it serves, with English and, in several states, Spanish, Chinese, and Vietnamese versions. The mailing and fax instructions printed on the form are region-specific, so using a form from the wrong state can delay processing. If downloading is a problem, call Member Services at 1-800-777-7902 and ask for a copy by mail, or ask to make the change over the phone.
Filling Out the Form Section by Section
The form is divided into lettered sections. Not all of them apply to every change.
Section A: Your Information
Check the box identifying yourself as the subscriber, the subscriber’s spouse or domestic partner, a dependent child age 18 or older, or the parent or legal guardian of a minor subscriber. Fill in your first name, middle initial, last name, date of birth, gender, Social Security number, and medical record number. If this change is to one of those fields (a legal name change, for instance), enter the new information here.
You will also provide a home address (no P.O. boxes), a mailing address, a primary phone number, and an email. The Colorado version, and some others, include a tobacco-use question for anyone 21 or older, because tobacco use can affect premium rates.
Section B: The Changes You Want to Make
This is a checklist. Mark every change that applies. The options split into two groups.
Changes you can make only during open enrollment or a special enrollment period:
- Changing plans.
- Combining accounts.
- Adding medical coverage for a family member.
- Adding yourself as the subscriber on an existing family account.
Changes you can make at any time:
- Ending coverage for yourself or a family member.
- Switching the subscriber on the account.
- Changing the parent or legal guardian on a child-only account.
- Updating personal information from Section A (name, SSN, date of birth, gender).
- Reporting that someone on the account has stopped using tobacco.
If your change falls into the “any time” group, the form directs you to skip the qualifying-life-event sections (typically D and E) and go to the signature. If you are adding coverage or changing plans, you’ll complete those later sections.
Section C: Family Members Affected
List every family member whose coverage is changing. For each, provide full legal name, date of birth, gender, Social Security number, and medical record number, and check whether you are adding or ending medical coverage for that person, including any optional dental coverage. The form usually has slots for a spouse or domestic partner and two or three dependents. If you have more, print an extra copy of that page and attach it.
Sections D and E: Life Event and Signature
If you are adding coverage or switching plans outside of open enrollment, Section D asks for the type of qualifying life event and the date it occurred. Section E is where you, and in some cases your spouse, sign and date to certify that the information is accurate.
Documents to Attach
Kaiser verifies most changes with supporting records. Gather these before you submit:
- Name change: a court-certified name change decree, marriage certificate, or divorce decree showing the new name. The form itself instructs you to “include legal documentation of the change.”
- Adding a newborn: a birth certificate or hospital record showing the child’s name and date of birth.
- Adoption or foster placement: legal placement papers or a final adoption order.
- Marriage: a marriage certificate.
- Divorce or legal separation: the final decree or court order.
- Loss of other coverage: a letter from the previous insurer or employer confirming the end date.
If you are also changing your name with the Social Security Administration, do that first when possible. The SSA typically mails a replacement card within 5 to 10 business days, and having federal records match avoids mismatches with your insurance file.
Deadlines and Effective Dates
For qualifying life events (marriage, birth, adoption, loss of other coverage, and similar changes), you have 60 days from the date of the event to enroll or change your plan. Miss the window and you may have to wait until the next open enrollment period.
The effective date depends on the event. Coverage for a newborn or newly adopted child is retroactive to the date of birth or placement, provided you enroll within the deadline. Coverage for a new spouse generally starts the first day of the month after you select a plan. When you are replacing lost coverage, the start date lines up with the day your prior coverage ended so there is no gap.
The timing matters more than people often assume. If you delay reporting a new baby, any care the child receives before enrollment is technically uncovered. Retroactive coverage only takes effect once you finish enrollment inside the 60-day window.
How to Submit It
Once the form is signed and the documents are attached, you have two options:
- Mail the packet to Kaiser Permanente, P.O. Box 23127, San Diego, CA 92193-9921. This address appears on multiple state versions, but confirm the address printed on your state’s PDF before sending.
- Fax the packet toll-free to Membership Administration at 1-855-355-5334.
Keep a copy of everything you send, including any fax confirmation or postal tracking receipt. If something gets lost, those records are how you prove you met the 60-day deadline.
You can also call 1-800-777-7902 to make some changes by phone, though the representative may still ask you to follow up with a signed form and documentation.
What to Expect After Submission
Membership Administration reviews the form and verifies the documents. Processing times vary for individual and family plans sent by mail or fax, so plan on checking your kp.org account about two weeks after submission. If the changes aren’t showing, follow up with Member Services.
You will get a confirmation through the online portal, by mail, or both. A new membership card arrives by mail when one is needed, such as after adding a dependent or changing your name. Check your next billing statement: adding a dependent increases your monthly premium, removing one decreases it, and the adjusted amount should match the effective date of the change.
If You Get a Premium Tax Credit
Members receiving advance premium tax credits need to report household and income changes promptly. The IRS calculates the credit from the household size and income you reported at enrollment. If those numbers change and you don’t update them, the credit keeps flowing at the old rate and the difference gets reconciled on your tax return.
For tax years beginning in 2026, there is no cap on how much excess advance premium tax credit you must repay. If you received more than you were entitled to, you owe the full difference, which either reduces your refund or increases your balance due. Prior years applied income-based repayment caps; those no longer apply.
The reverse is also worth knowing. If your household grew and you didn’t report it, you may have been entitled to a larger credit than you received, and you can claim the additional amount on Form 8962 when you file.