NEW! To apply online: please click here.

To make sure all steps are completed we recommend that you Print this page.

You can download and print the application and medical questionnaire. You will need the free Adobe Acrobat Reader to read this file.

1. Use a black or blue ink pen to complete the application for yourself and/or family members.
   The application MUST be completed for each applicant. Failure to do so will delay the application procces.

   Do not use a photocopy of the form. Be sure to answer all questions carefully and accurately for all members applying. Application and questionnaire must be completed and submitted by the applicant, or parent or guardian for children under 18. Spouses and dependent children under age 21 and dependent children who are full-time students under age 23 are eligible for coverage. Note: Please provide date of last menstrual period for all applicants between ages 12 - 55.
   

2. Each family member must complete an application.
    
3. Please return the completed forms to:
   
   GORDON PAUL
   Kaiser Permanente Personal Advantage Plan
   1368 W. Herndon Avenue, Suite 101
   Fresno, CA 93711
   
   Phone: 1-888-492-7245 
   Fax: 559-431-0009 (Faxed Applications are processed faster.)



4. We will review your application upon receipt. To avoid processing delays, your application information must be completed in full. Be sure to sign and date the application. If we have no questions from this review, you can expect a written decision of your membership status within two weeks.
    
5. Do not cancel your current coverage. Receipt of your application does not imply acceptance. Kaiser Permanente will notify you by mail upon acceptance.

All applications are subject to medical review. Each applicant will be accepted or denied based on medical information supplied in their application and medical questionnaire.