Online Application

Fastest Method - Complete and submit your application 24 hours a day, 7 days a week online.

Printable Application

You can download and print the application or have one sent to you via mail. Note: Each enrolling family member must complete a separate application for membership.

• Use a black or blue ink pen to complete the application for yourself and/or family members.
  Be sure to answer all questions accurately for all members applying. Applications must be completed and submitted by the applicant, or parent/guardian for children under 18. Be sure to sign and date your application.

  Additional Resources
  • Disclosure Forms
  • Child Only Brochure
  • Notice of Language Assistance
  • Spanish Application

• Please mail the completed application to:

  eKaiserinsurance.com
  2235 Sara Way
  Carlsbad, CA 92008

• Or fax completed application to:

  888-436-4342

• Your application will be reviewed upon receipt. If the application is complete, you will receive a written decision of your membership status within three weeks. To receive an email verification and notice of application status, please include your email address on the cover page and submit with your application.

  Do not cancel your current coverage. Receipt of your application does not imply acceptance. Kaiser Permanente will notify you by mail upon acceptance.

Request Mail Application

Call (800) 915-0501 or submit request below...