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

1. Using a black or blue ink pen, complete the Personal Plans detailed health questionnaire for yourself and for each member of your family applying for coverage.
   • Be sure to answer all questions carefully and accurately.
   • Questionnaire must be completed and signed by applicant or parent/guardian only.
   • Page 2 needs to be completed only by the head of household.
   • Each adult must sign their own application on page 3.
   • Completion of page 4 is not necessary by Georgia applicants.
2. Enclose a check for your/your family's first month's premium. This check will be deposited only if you are accepted for membership. If you are not accepted, it will be returned to you.
    
3. Make checks payable to Kaiser Permanente. Do not send cash. Please send to:
   
   GORDON PAUL
   Kaiser Permanente Personal Advantage Plan
   1368 W. Herndon Avenue, Suite 101
   Fresno, CA 93711
   
   
4. Do not cancel your current coverage. Coverage will begin only if the application is approved by Kaiser Foundation Health Plan of Georgia, Inc.. Receipt of your premium check does not imply acceptance. Kaiser Permanente will notify you by mail upon acceptance. If approved, coverage will begin on the effective date inserted by Kaiser Foundation Health Plan of Georgia, Inc. in the written notice of approval to the applicant. The absence of written approval will not imply approval.

Rememberto avoid delays, go through the application thoroughly to make sure you have answered all of the questions and signed where required.

All applications undergo a medical review. Each applicant will be accepted or rejected based on health habits and history.

If you have any questions or need assistance completing your application, please call 1-888-492-7245. Once we receive your application(s), it will be processed in approximately 10 business days. Then, we will send you a letter notifying you whether or not you have been approved for coverage. We will not deposit your check unless you are accepted for membership