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Carrier Agreements

Kaiser Virginia 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 understand that Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. (Health Plan), will rely on the information provided in this application. If any information is found to be fraudulent or intentionally misrepresented, then Health Plan may choose to deny coverage or terminate coverage back to the coverage effective date or the date of the fraud or intentional misrepresentation of material fact for me and all my dependents (rescission). I will be given 30 days advance notice by Health Plan before coverage is rescinded. In the event of rescission, I agree to be responsible for all medical costs incurred by Health Plan, and Health Plan may reduce those costs by any premiums paid. Health Plan will refund any premiums paid back to the date of the denial or the effective date of the rescission of coverage less any medical costs incurred by Health Plan. If medical costs exceed the amount of premium paid, I agree to be responsible to Health Plan for the difference.

  • The applicant or his or her authorized representative may request a copy of the completed application. For more information, please call 301-468-6000 or 1-800-777-7902.

  • WARNING: ANY PERSON WHO, WITH THE INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT MAY HAVE VIOLATED STATE LAW.