Kaiser Georgia Application Agreement

Sign the application agreement

Important: All applicants and dependents 18 and older must read, sign, and date below. If the primary applicant is a child under 18, then his or her parent or legal guardian must sign. By signing, the parent or legal guardian agrees to be responsible for paying all premiums, copays, coinsurance, and deductibles for all the applicants listed on this application. A copy of your agreement with your signature is as valid as the original. If signatures are missing, we will cancel the application. If there are more than 3 dependents 18 and older signing, please attach a copy of this page with the additional signatures.

• I have provided true and correct answers to all the questions on this form to the best of my knowledge.

• I know that my information on this form will only be used to determine ongoing eligibility for health coverage and will be kept private as required by law.